ORIGINAL ARTICLE
Trans R Soc Trop Med Hyg 2014; 108: 632–638 doi:10.1093/trstmh/tru122 Advance Access publication 16 August 2014
Factors contributing to home-based acceptability of rapid testing for HIV infection among the inner city commuter population in Johannesburg, South Africa Keith Muloongoa, Ndumiso Tshumaa, Lucy Chimoyib, Geoffrey Setswec, Bismark Sarfoe and Peter Nyasulud,f,*
*Corresponding author: Present address: School of Health Sciences, Monash University, South Africa. Tel: +27 11 950 4287; E-mail: [email protected]
Received 14 March 2014; revised 26 June 2014; accepted 27 June 2014 Background: The study aimed to determine factors contributing to the acceptability of home-based HIV counselling and testing (HBHCT) among commuters in Johannesburg inner city. Methods: Simple random sampling was used to select participants in a venue based intercept survey at Noord Street taxi rank in Johannesburg central business district. A total of 1146 individuals were interviewed and logistic regression analysis assessed factors associated with HBHCT acceptability. Results: HBHCT acceptability was 64%. Home testing was preferred as an alternative to testing at a health facility. High school education (adjusted odds ratio [aOR] 0.61, CI 0.46–0.85), inner city residence aOR 0.70, CI 0.52–0.94), previous HIV testing in the hospital (aOR 0.22, CI 0.15–0.32) and at home (aOR 0.18, CI 0.11–0.27) were significantly less likely associated with HBHCT acceptability. Being married (aOR 1.64, CI 1.15–2.32), recent HIV testing (aOR 1.85, CI 1.15–2.99) and having experienced negative health worker attitude (aOR 2.41, CI 1.66–3.48) were significantly more likely associated with HBHCT acceptability. Conclusions: High acceptability of HBHCT among urban-based commuters plus factors that would deter HBHCT acceptability were identified. Further research to identify strategies to improve HBHCT acceptability among commuter populations is needed. Keywords: Commuter population, Counselling, HIV, HIV testing, Home-based testing, Johannesburg
Introduction Worldwide, more than 35 million people now live with HIV/AIDS, 3.3 million of whom are under the age of 15. In 2012, an estimated 2.3 million people were newly infected with HIV and 260 000 of these were under the age of 15. Every day, nearly 6300 people contract HIV: approx. 262 every hour. Since the beginning of the epidemic, more than 75 million people have contracted HIV and nearly 36 million have died of HIV-related causes.1 More than 70% (25 million) of people living with HIV live in sub-Saharan Africa including 88% of the world’s HIV-infected children. In 2012, an estimated 1.6 million people in the region became newly infected. An estimated 1.2 million adults and children died of AIDS, accounting for 75% of the world’s AIDS deaths in 2012.1 The estimated overall HIV prevalence rate in South Africa
is approximately 10% representing the highest in the world. Among adults aged 15–49 years, an estimated 15.9% of the population are living with HIV.2 The estimated prevalence of HIV in Gauteng is 16.5% which is higher than the national estimate. Out of the 12 272 263 people living in Gauteng only 1 447 200 (11.8%) individuals received HIV counselling and testing (HCT).3 In this context, it is clear that HIV is still a very important infection that must be controlled and prevented in subSaharan Africa and more especially in South Africa. In the past, a lot of resources have been put into stemming the tide of HIV with some noticeable achievements. Donor fatigue and dwindling resources call for a re-look at every opportunity not only to advance an increase in HCT uptake but also to focus on key at-risk populations within the society that can benefit from HCT services.
# The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: [email protected].
632
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
a Community AIDS Response, Norwood, Johannesburg, South Africa; bWits Reproductive Health and HIV Research Institute (WHRI), Hillbrow, Johannesburg, South Africa; cHIV/AIDS, STI and TB (HAST) Research Program, Human Sciences Research Council Pretoria, South Africa; dSchool of Public Health, University of the Witwatersrand, Johannesburg, South Africa; eDepartment of Epidemiology and Disease Control, School of Public Health, University of Ghana, Legon-Accra, Ghana; fSchool of Health Sciences, Monash University, Ruimsig, Johannesburg, South Africa
Transactions of the Royal Society of Tropical Medicine and Hygiene
treatment and care efforts although they are most often difficult to reach due to their mobility, leaving HCT service providers with no option but to intercept them in open public places such as taxi ranks, bus and train stations. The goal was to find out whether such populations could easily be accessed through the HBHCT approach.
Methods Study design The study used a simple random sampling technique to select participants in a venue based intercept survey at the four corners of Noord Street taxi rank in Johannesburg inner city central business district (CBD). The simple random technique entailed the selection of an even number from a bowl with numbers one to ten. Field workers approached potential participants walking towards the corners that served as intercept points and sought verbal consent prior to allowing potential participants to pick the numbers from a bowl. Only those who picked an even number were allowed to respond to a closed ended questionnaire.
Study setting The Noord Street taxi rank is by far the largest and busiest in Johannesburg and is positioned at the heart of the inner city in the CBD.14 During apartheid, the CBD was Johannesburg’s commercial centre, home to many of the city’s national and international companies. Following the fall of apartheid, the CBD made a swift and disorderly transition, absorbing many of the urban poor while a majority of businesses and corporations fled to upper class suburbs such as Sandton. Individuals came to the inner city from townships, which were inconveniently far from businesses, for cheaper transportation, job opportunities and more convenient access to social amenities. The CBD also saw a large influx of individuals from other provinces and neighbouring countries.15 The 2011 census reported that Gauteng province absorbed a net migration of 1 037 871 individuals between 2001 and 2011, the highest in the country.16 As a result, the CBD has transformed from a spacious, well-maintained business district, to a densely populated, culturally diverse, and poorly regulated city centre over a short period of time.15 The taxi rank is Johannesburg’s primary transit centre for all vehicles operating in South Africa’s mini-taxi system. It is common knowledge that taking a mini-taxi is often inconvenient and time consuming, but is also the most cost effective way of getting from one part of the city to another. Therefore, the minitaxi system is primarily utilised by individuals without the means to afford more comfortable and convenient modes of transport such as private cars or metered taxis. Most passengers use the Noord taxi rank as a platform to start their commute or switch directions and travel to a different area of the city. Individuals moving through the Noord taxi rank come from townships at the city periphery, and from the CBD itself. The CBD has high levels of unemployment and is adjusting to relatively new increased population densities. Often, the only tangible housing options for individuals living in the CBD are illegal, informal renting spaces, which often operate out of dilapidated buildings. It is estimated that 100 000 of the city’s residents utilise informal rental housing
633
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
Bateganya et al.4 reiterated that low uptake of HIV voluntary counselling and testing (VCT) is one of the HIV prevention intervention strategies that may have hindered global attempts to prevent new HIV infections. It might also have limited the scale-up of HIV care and treatment to infected persons. In this HIV epidemic era, a renewed focus seems to have shifted towards prevention efforts thereby making VCT a priority intervention. For that reason, there is a need to focus on methods that would ultimately increase the uptake of HCT. As a result of this emphasis, home based HCT (HBHCT) delivery models may be an effective avenue to enhance uptake of HCT among individuals in the communities. Such an approach might lead to an improvement in HIV/AIDS patients’ access to early treatment, and also prevent occurrence of new infections.4–6 Scale up of HCT uptake may not only enhance early detection of HIV infection, but also could be a mode of facilitating opportunity to early treatment, care and support for those who are infected. HBHCT offers the opportunity to improve VCT uptake as long as government policy to implement such an approach is promulgated. Individuals advocating for HBHCT have forecast increasing rates of home testing among individuals in various communities.5–7 Since HBHCT appears an easier program to execute,8 we share the opinion that availability of rapid home HIV test kits will dramatically scale up rates of HIV detection among communities and hard-to-reach populations. Despite the notion that no evidence exists, large-scale door-to-door testing has shown feasibility in resource-poor settings that experiences significant stigma surrounding HIV/AIDS.9,10 The concept of HBHCT is not new. However, full involvement of community care workers, commonly known as caregivers, entrusted with the responsibility to provide this service by the Department of Health in South Africa has not yet taken place. It is fully established and generally accepted that HCT is a critical gateway for addressing HIV prevention as it provides a way of linking people to treatment, care and support. Hence there is growing interest in expanding HIV testing coverage through the implementation of innovative models such as HBHCT.7 There are two studies on HBHCT that have been conducted in South Africa, namely: ‘Modelling the effectiveness of combination prevention from a house-to-house HIV testing platform in Kwazulu-Natal, South Africa’11 and ‘Client characteristics and acceptability of a home-based HIV counselling and testing intervention in rural South Africa’.7 Both of these studies were done in rural settings of KwaZulu-Natal province. Similar studies have also been conducted in Uganda,12 Kenya,6,10 Zambia5 and one global systematic review.13 The target populations for these studies were community members in urban and/or rural settings. One of the Kenyan studies used a mixed methods design while the rest were all quantitative. None of them focused on commuter populations which are groups of people who travel some distance to and from work or in search of work on a regular basis. These are a critical group of people for whom it is difficult to offer health services because they leave their homes early in the morning and come back late at night and yet they form an important group not to be ignored in the fight against HIV transmission. Evidently, no studies of this nature have been done in Gauteng province. This study therefore sought to understand the factors contributing to acceptability of rapid testing in homes among the commuter population in the inner city of Johannesburg. Commuter populations are key target groups for HCT, prevention,
K. Muloongo et al.
in the inner city.14 The Noord Street taxi rank though with such a bustling number of commuters has had limited health intervention studies undertaken.
Data collection
Results Frequency distribution of study characteristics according to gender
Data were collected using an electronic questionnaire loaded in Tablet personal computers during a two-day HCT campaign at the taxi rank in May 2013. The fieldworkers interviewed participants and recorded responses directly into Tablets. This followed a community outreach campaign organised in conjunction with the Department of Health which targeted taxi ranks in the Johannesburg Metropolitan health district. The measures used for data collection were categorised into socio-demographic characteristics, history of testing and barriers to testing. Socio-demographic characteristics included participant age (under 15, 15–19, 20–24 and 25–35 years), marital status (single, married, divorced, cohabitating), occupation (formally employed, self-employed, student, not employed), education (below high school level, high school level, tertiary qualification which included certificate, diploma and degree), distance to the nearest clinic (0–10, 11–20, 21–30, .30 km), place of residence (inner city and outside inner city) and place of work (inner city and outside inner city). HIV testing history included the most recent time the participant had tested for HIV under the categories, ,1 year, 1–2 years and ≥3 years; persons with no prior HIV test comprised the reference group. The participants were also asked the total number of times they had tested in the previous year and were categorised as 0, 1, 2, 3, 4, 5, 6 or never. The barriers to HIV testing were categorised as emotional and cognitive, social, economic and structural. The participants who had tested and not tested for HIV in the past were asked to identify the obstacles to testing for HIV. Home testing and mobile outreach facilities were combined to form one variable used as the outcome for analysis.
Among participants who preferred home testing, 59.0% of 732 (n¼432) had their HIV test less than a year ago compared with only 50.0% of 414 (n¼207) among participants who did not prefer home testing and had their HIV test less than a year ago. Approximately 83% (82.5%, n¼522) of those who previously visited a clinic for HIV testing preferred taking subsequent tests at home and this proportion was significantly higher than those who previously visited a clinic for HIV testing but did not prefer HBHCT (49.0%, n¼179, p¼0.0001). Participants who preferred HBHCT cited health worker attitudes as one of the major barriers to HIV testing (27.9%, n¼204, p,0.001). The majority of the participants surveyed had knowledge of HCT, were living together with people with HIV/AIDS, had family members with HIV/AIDS and knew people who had died as a result of an HIV/AIDS related illness (Table 2).
Statistical analysis
Unadjusted factors associated with home-based HIV counselling and testing
Statistical analysis was performed using STATA software version 1217 and included descriptive, bivariate and inferential procedures. Descriptive analyses looked at the frequencies of selected responses given by participants. Differences among male and female participants were evaluated by x2 test. This was also performed to examine differences in the outcome with selected variables. Univariate logistic regression analysis were performed to assess the relationship between each variable construct and the outcome. Variables in univariate analysis with a p,0.05 were included in the multivariate analysis. Multiple logistic regression analysis was performed, considering the acceptability of home testing variable as a dependent variable and all the sociodemographic and HIV testing factors as independent variables. A forward selection procedure was applied. Variables with a p,0.05 were deemed statistically significant and were included in the multivariate model. The multiple logistic regression models were constructed to adjust for the confounding effect age and place of residence. The final model presented the ORs and their corresponding 95% CIs.
Factors associated with HBHCT between socio-demographic and HIV testing related choices were assessed in the univariate logistic regression model. Being married was positively associated with HBHCT acceptability compared with being single (OR 1.58, 95% CI 1.19–2.11). Those with a secondary school education were 25% less likely to prefer HBHCT compared with those without (OR 0.75, 95% CI 0.56–1.00). Participants living 11–20 km (OR 0.61, 95% CI 0.44–0.85) and more than 30 km (OR 0.73, 95% CI 0.25–0.56) away from the nearest health facility were less likely to prefer HBHCT compared with those living near the clinic. Residing (OR 0.69, 95% CI 0.54–0.88) in the inner city and working (OR 0.59, 95% CI 0.54–0.89) outside the inner city were less likely associated with HBHCT acceptability than residing within the inner city. Participants who had an HIV test less than a year ago were 65% more likely to be associated with HBHCT compared with those who never tested (OR 1.65, 95% CI 1.20–2.25). Participants who previously had an HIV test at a hospital (OR 0.24, 95% CI 0.17–0.34) or a home/mobile outreach facility (OR 0.16, 95% CI 0.10–1.23) were less likely to be associated with
634
Characteristics of HIV testing practices according to home testing preferences
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
Out of the 1146 participants, 49.5% were male (n¼567) while 50.5% were female (n¼579). The majority (42.1%, n¼483) of the participants were in the age group 20–24 years. Most of the participants were single (69.9%, n¼801) showing more single female participants (75.1%, n¼435) compared to their male counterparts (64.6%, n¼366). Nearly two-fifths of the female and male participants were unemployed (37.3%, n¼216, females and 39.7%, n¼225, males) respectively. More women (50.7%, n¼294) had a high school qualification compared with men (36.0%, n¼204). Slightly, above half of the participants resided and were employed in the inner city. The majority of the participants (63.9%, n¼732) preferred a rapid test (HBHCT) performed at their homes (61.7%, n¼357 females and 66.1%, n¼375 males) respectively (Table 1).
Transactions of the Royal Society of Tropical Medicine and Hygiene
Table 1. Frequency distribution of demographic characteristics according to gender
Table 2. Comparison of frequency distribution of HIV testing practices according to home testing preferences
Characteristics
Characteristics
Female n¼579 n (%)
p-value
Does not prefer home testing n (%)
Prefers home testing n (%)
p-value
123 (16.8) 432 (59.0) 105 (14.3) 15 (2.1) 57 (7.8)
0.002
522 (82.5) 69 (10.9) 42 (6.6)
,0.0001
570 (77.9) 162 (22.1)
NS
492 (67.2) 240 (32.8)
NS
393 (53.7) 339 (46.3)
NS
444 (60.7) 288 (39.3)
NS
210 (28.7) 204 (27.9)
,0.0001
0.009 36 (6.4) 126 (22.2) 264 (46.6) 141 (24.9) 0.018 366 (64.6) 6 (1.1) 186 (32.8) 9 (1.6) NS 108 (19.1) 183 (32.3) 225 (39.7) 51 (8.9) 0.007 186 (32.8) 204 (36.0) 177 (31.2) ,0.0001 426 (75.1) 66 (11.6) 18 (3.2) 57 (10.1) 0.002 324 (57.1) 243 (42.9) 0.003 345 (60.9) 222 (39.2) NS 375 (66.1) 192 (33.9)
NS: not significant.
HBHCT compared with those who previously tested in a clinic. Lastly participants who experienced a negative health worker’s attitude were 59% more likely to prefer HBHCT than those who did not have such an experience (OR 1.59, 95% CI 1.11–2.28). Lack of confidentiality in the home as a potential hindrance to HBHCT was less likely associated with HBHCT acceptability (OR 0.55, 95% CI 0.39–0.76) (Table 3).
Adjusted factors associated with home-based HIV counselling and testing In the adjusted logistic regression analysis, being in the age-group 25–35 years (aOR 0.48, CI 0.34–0.67), having secondary school education (aOR 0.61, CI 0.46–0.85), residing in the inner city
Last HIV test Never tested 97 (23.4) ,1 year 207 (50.0) 1–2 years 54 (13.0) 2–3 years 5 (1.2) .3 years 51 (12.3) Place of previous HIV test Clinic 179 (48.3) Hospital 96 (26.7) Home/mobile 90 (25.0) outreach Knowledge of HCT centres Yes 336 (81.2) No 78 (18.8) Knowledge of persons with HIV Yes 282 (68.1) No 132 (31.9) Knowledge of family members with HIV Yes 231 (55.8) No 183 (44.2) Knowledge of HIV-related deaths Yes 255 (61.6) No 159 (38.4) HIV testing barriers None 108 (26.1) Health worker 66 (15.9) attitudes Difficulty in 48 (11.6) accessing services Lack of ART 21 (5.1) Lack of 135 (22.6) confidentiality Presence of fee for 30 (7.3) HIV testing Others 6 (1.5)
84 (11.5) 33 (4.5) 144 (19.7) 45 (6.1) 12 (1.6)
ART: antiretroviral therapy; HCT: HIV counselling and testing; NS: not significant.
(aOR 0.70, CI 0.52–0.94), visiting a hospital (aOR 0.22, CI 0.15– 0.32) and testing at home or mobile outreach (aOR 0.18, CI 0.11–0.27) were significantly less likely to be associated with HBHCT acceptability. Being married (aOR 1.64, CI 1.15–2.32), having tested less than a year ago (aOR 2.03, CI 1.41–2.93) or between 1–2 years ago (aOR 1.85, CI 1.15–2.99) and experiencing negative attitudes from health workers (aOR 2.41, CI 1.66–3.48) were significantly more likely to be associated with HBHCT acceptability (Table 3).
635
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
Age group ,15 years 69 (11.9) 15–19 years 135 (23.3) 20–24 years 219 (37.8) 25–35 years 156 (26.9) Marital status Single 435 (75.1) Cohabiting 12 (2.1) Married 117 (20.2) Divorced 15 (2.6) Occupation Unemployed 216 (37.3) Self employed 129 (22.3) Formally employed 135 (23.3) Student 99 (17.1) Education level Below high school 138 (23.8) High school 294 (50.8) Tertiary 147 (25.4) Distance to nearest clinic 0–10 km 366 (63.2) 11–20 km 114 (19.7) 21–30 km 48 (8.3) .30 km 51 (8.8) Place of residence Inner city 333 (57.5) Outside inner city 246 (42.5) Area of employment Inner city 360 (62.2) Outside inner city 219 (37.8) Home testing preference Yes 357 (61.7) No 222 (38.3)
Male n¼567 n (%)
K. Muloongo et al.
Table 3. Univariate and multivariate analysis of factors associated with home-based HIV testing Factor
Unadjusted OR (95% CI)
p–value
OR (95% CI)
p–value
1.00 1.22 (0.76–1.98) 0.95 (0.61–1.48) 0.68 (0.43–1.08)
0.411 0.828 0.102
1.00 ND ND 0.48 (0.34–0.67)
NA NA ,0.0001
1.00 1.28 (0.47–3.43) 1.58 (1.19–2.11) 1.06 (0.46–2.46)
0.629 0.002 0.886
1.00 ND 1.64 (1.15–2.32) ND
NA 0.006 NA
1.00 0.75 (0.56–1.00) 1.18 (0.85–1.65)
0.054 0.314
1.00 0.61 (0.46–0.85) ND
,0.0001 NA
1.00 0.61 (0.44–0.85) 0.82 (0.48–1.38) 0.73 (0.25–0.56)
0.003 0.45 ,0.0001
1.00 ND ND ND
NA NA NA
1.00 0.69 (0.54–0.88)
0.003
1.00 0.70 (0.52–0.94)
0.017
1.00 0.69 (0.59–0.89)
0.003
1.00 ND
NA
1.00 1.65 (1.20–2.25) 1.53 (1.00–2.34) 2.37 (0.83–6.74) 0.88 (0.56–1.40)
0.002 0.047 0.107 0.592
1.00 2.03 (1.41–2.93) 1.85 (1.15–2.99) ND ND
,0.0001 0.012 NA NA
1.00 0.24 (0.17–0.34) 0.16 (0.10–1.23)
,0.0001 ,0.0001
1.00 0.22 (0.15–0.32) 0.18 (0.11–0.27)
,0.0001 ,0.0001
1.00 1.59 (1.11–2.28) 0.90 (0.59–1.38) 0.81 (0.45–1.46) 0.55 (0.39–0.76) 0.77 (0.46–1.29) 1.03 (0.38–2.82)
0.012 0.626 0.482 ,0.0001 0.325 0.965
1.00 2.41 (1.66–3.48) ND ND ND ND ND
,0.0001 NA NA NA NA NA
NA: not applicable; ND: not detected.
Discussion There is growing interest in the expansion of HIV testing services through the implementation of innovative models such as the
636
HBHCT7 in order to link people to treatment, care and support. Although some studies have been conducted on HBHCT,7,10,11,13,14 none of them focused on the commuter population, which constitutes a critical group of people who are key to
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
Age group ,15 years 15–19 years 20–24 years 25–35 years Marital status Single Cohabiting Married Divorced Education level Below high school High school Tertiary Distance to nearest clinic 0–10 km 11–20 km 21–30 km .30 km Place of residence Inner city Outside inner city Area of employment Inner city Outside inner city Last HIV test Never tested ,1 year 1–2 years 2–3 years .3 years Place of previous HIV test Clinic Hospital Home/mobile outreach HIV testing barriers None Health worker attitudes Difficulty in accessing services Lack of antiretroviral therapy Lack of confidentiality Presence of HIV testing fee Other factors
Adjusted
Transactions of the Royal Society of Tropical Medicine and Hygiene
think about it, knowing ones HIV status, being HIV-positive and not feeling at risk of having or acquiring HIV7 which are different to the factors that our study exposes. Our study, which was based in a typical urban setting, highlights statistically significant factors associated with HBHCT as being married, having tested less than one year ago and having experienced negative health worker attitudes at health facilities. Each time these factors are encountered we should bear in mind that the chances of HBHCT preference are more likely going to be promulgated. Factors less likely associated with HBHCT have shown to be issues to do with levels of education, residing more than 10 km from the nearest health facility and taking an HIV test at a hospital as opposed to a clinic. We observed that more participants (522 vs 179) who had their previous HIV test at a clinic preferred home testing, while more of those who preferred home testing (204 vs 66) expressed poor health worker attitudes as a main reason for their choice. Whereas poor health worker attitude drives away a significant number from testing in the clinics, it creates an opportunity for a parallel intervention using HBHCT approach. This study supports the findings of a study done in Tanzania in which married couples idealised testing at home as a way of strengthening and deepening their marital relationship, because it provided an opportunity to reflect upon fundamental values and priorities in a relationship.21 An HBHCT will allow people to test when they want to and how they want to, in the privacy of their own homes. This will allow a whole new population of people to know their HIV status without having to go to a local testing centre. Having an HIV test openly and easily available might also reduce the stigma surrounding both the illness and getting tested for it. However, a disadvantage of HBHCT is that a person could be identified as having tested for HIV if the HBHCT care givers visit homes in neighbourhoods where they are known. But this could be avoided if the care givers work in more distant locations with less familiar personnel. Recently, the USA Food and Drug Administration (FDA) approved a home-based HIV testing kit called OraQuick which underscores the need to embrace home-based testing, especially by countries in sub-Saharan Africa. The major characteristic and advantage of this study was the direct access it provided to targeted commuter populations making it easier and cost-effective because survey field workers readily reached a large number of commuters. In spite of these advantages, there were some limitations to be noted. The main limitations of the study were ‘information bias’ resulting from differential recall among study participants as some of them had tested for HIV more than a year prior to the survey. Other limitations include: lack of generalizability of the study results as potential participants who were randomly approached and declined to respond to the questionnaire for one reason or another may have influenced a non-response error whereby we could not be sure that those who responded were not in some way different from those that chose not to respond; social desirability bias would have occurred due to the sensitive nature of HIV information as the survey was done in an open, public place; and lastly, venuebased intercept surveys that are too lengthy and/or complex to be completed owing to skips, branching, or other complexities prove challenging to administer. However none of these issues were encountered in this study.
637
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
the transmission of HIV. The provision of HBHCT will ensure that clients receive HIV test results quickly and will serve as a means to identify first time testers who would not have visited a health facility to test for HIV. This model of HBHCT will also allow for the utilisation of lay counsellors and community based health workers in order to decongest the health facilities and reduce the disease burden. HBHCT will provide the opportunity to test couples and/or the entire family in one household. However HBHCT poses challenges such as counsellor fatigue, safety and security in the inner city, partner violence and abuse, lack of confidentiality among family members, consent and refusal issues.18 This is one of the first studies in South Africa to report on acceptability of HBHCT among a commuter population using urban public transport system. The results show an overall acceptability level of 64%. This is slightly lower than 69% of participants in the home based HCT cluster randomised controlled trial conducted in rural South Africa,19 and 76.1% of those who indicated their willingness to be HIV tested following the home-based HCT delivery process in urban and rural population in Zambia. Acceptability did not differ by sex but was higher in the rural compared with urban areas (83.6% vs 70.7%). 5 This shows that acceptability of HBHCT uptake seems to be higher in rural settings as opposed to urban settings. Therefore, there is a need to enhance HCT intervention efforts through advocacy, communication and social mobilization in this setting. In this study 68% of the participants lived within 10 km of a health facility. The assumption was that the commuter population would prefer open spaces such as taxi ranks for testing and not testing in their homes. According to this study, testing at home is better than testing at a health facility among commuter population. The majority of participants cited health worker attitude as a reason for deciding to test at home. The implication for this choice is that health facilities need to study the kinds of health worker attitudes necessary to draw commuter populations or indeed any other HCT seekers to health facilities. Any improvement initiatives should take into account the factors necessary to attract ‘the would-be testers’ to health facilities. A Zambian study that randomised community clusters to HCT either at a local clinic or at an optional location (most commonly the home) found an almost five-fold increase in counselling and testing in the optional location group.20 In our study health facility HCT visit experience had a negative influence as about 83% of those who previously visited a health facility subsequently preferred home testing. This creates an opportunity to supplement efforts that would increase HCT uptake by taking a home-based approach to offering HCT. This can be done through community health workers providing HCT in addition to other health related services such as screening for TB and home-based care provided to the HIV positive individual as well as targeting other members of the household for HCT services.18 It is most important to better understand the correlates of HIV testing in order to ensure that HIV prevention programmes and HCT outreach actively promotes HIV testing among this commuter population. A study on client characteristics and acceptability of an HBHCT intervention in rural South Africa found that the most common reasons for not testing were, among others: not being ready/feeling scared/needing to
K. Muloongo et al.
Conclusions
7 Naik R, Tabana H, Doherty T et al. Client characteristics and acceptability of a home-based HIV counselling and testing intervention in rural South Africa. BMC Public Health 2012;12:824. 8 Walensky RP, Paltiel AD. Rapid HIV testing at home: does it solve a problem or create one? Ann Intern Med 2006;145:459–62. 9 Kimaiyo S, Were MC, Shen C et al. Home-based HIV counselling and testing in western Kenya. East Afr Med J 2010;87:100–8. 10 Low C, Pop-Eleches C, Rono W et al. The effects of home-based HIV counseling and testing on HIV/AIDS stigma among individuals and community leaders in western Kenya: Evidence from a cluster-randomized trial. AIDS Care 2013;25:97–107. 11 Alsallaq R, Baeten J, Hughes J et al. Modelling the effectiveness of combination prevention from a house-to-house HIV testing platform in Kwazulu Natal, South Africa, Sex Transm Infect 2011;87:A36.
Authors’ contributions: KM, NT and PN designed the research while KM and NT conducted research.KM, NT, GS, BS, PN and provided essential constructs for the writing of the manuscript. LC performed statistical analysis; KM, NT, GS, LC and PN wrote the paper. All authors read and approved the final version of the manuscript. PN is guarantor of the paper.
12 Sekandi JN, Sempeera H, List J et al. High acceptance of home-based HIV counseling and testing in an urban community setting in Uganda. BMC Public Health, 2011;11:26–9.
Funding: CARE International South Africa-Lesotho office provided funding for the primary data collection.
14 City of Johannesburg. Taxis. 2014 Official website of the City of Johannesburg. www.joburg.org.za/index.php?option=com_content &id=60. [accessed 27 January 2014].
Competing interests: None declared.
15 Ayala A, Geurts E, Ahmad P et al. Urbanising Africa: the city centre revisited. Experiences with inner-city revitalization from Johannesburg (South Africa), Mbabane (Swaziland), Lusaka (Zambia), Harare and Bulawayo (Zimbabwe). Rotterdam: Institute for Housing and Urban Development Studies. IHS Working Papers Series no. 26/2010.
Ethical approval: Approval to use data for this study was obtained from Community AIDS Response (CARe). Informed consent from individual participants was obtained at the time of primary data collection, no participant identifiers were obtained.
References 1 amfAR. Statistics: Worldwide. New York: The Foundation for AIDS Research; 2013. http://www.amfar.org/about-hiv-and-aids/factsand-stats/statistics--worldwide/ [accessed 14 June 2014]. 2 Statistics South Africa. Mid-year population estimates: 2013. Statistical release P0302. Pretoria: Statistics South Africa; 2013. http://beta2.statssa. gov.za/publications/P0302/P03022013.pdf [accessed 8 May 2014]. 3 PEPFAR Gauteng. Partnership to Fight HIV/AIDS in South Africa. Washington, DC: Office of the Global AIDS Coordinator; 2010. http:// www.pepfar.gov/countries/southafrica/ [accessed 15 June 2014]. 4 Bateganya MH, Abdulwadud OA, Kiene SM. Home-based HIV voluntary counseling and testing in developing countries. Cochrane Database Syst Rev 2009;4:CD006493. 5 Mutale W, Michelo C, Ju¨rgensen et al. Home-based voluntary HIV counselling and testing found highly acceptable and to reduce inequalities. BMC Public Health 2010;10:347.
638
13 Suthar AB, Ford N, Bachanas PJ et al. Towards universal voluntary HIV testing and counselling: a systematic review and meta-analysis of community-based approaches. PLoS Med 2013;10:8:e1001496.
16 Statistics South Africa. Census 2011. Statistical Release (Revised) P0301.4. Pretoria: Statistics South Africa; 2012. http://www.statssa. gov.za/publications/P03014/P030142011.pdf [accessed 25 February 2014]. 17 StataCorp. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP; 2013. 18 Taegtmeyer M, Blazer C, Escobar MC et al. Out of the clinic and into the home. Development of WHO/PEPFAR Home-Based HIV Testing and Counseling Support Tools. http://pag.aids2012.org/EPosterHandler. axd?aid=7082 [accessed 14 June 2014]. 19 Doherty T, Tabana H, Jackson D et al. Effect of home based HIV counselling and testing intervention in rural South Africa: cluster randomised trial. BMJ 2013;346:3481. 20 Fylkesnes K, Siziya S. A randomized trial on acceptability of voluntary HIV counselling and testing. Trop Med Int Health 2004;9:566–72. 21 Njau B, Watt MH, Ostermann J et al. Perceived acceptability of home-based couples voluntary HIV counseling and testing in Northern Tanzania. AIDS Care 2012;24:413–9.
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
The findings of this study indicate that HBHCT is acceptable among the urban-based commuter population in the inner city of Johannesburg. The study has also identified factors that would impact negatively on HBHCT acceptability among this key population. However, future HBHCT programmes should consider using existing urban infrastructure such as taxi ranks to develop strategies to reach a broader range of clients, and tailor HIV prevention intervention approaches and services to meet the unique needs of commuter populations. In view of the factors observed that would hinder HBHCT, we suggest training of health workers to improve client relations, use of trained lay counsellors, free HCT services and taking HCT to homes to enhance HCT uptake among commuter populations.
6 Negin J, Wariero J, Mutuo et al. Feasibility, acceptability and cost of home-based HIV testing in rural Kenya. Trop Med Int Health. 2009;14:849–55.
Trans R Soc Trop Med Hyg 2014; 108: 632–638 doi:10.1093/trstmh/tru122 Advance Access publication 16 August 2014
Factors contributing to home-based acceptability of rapid testing for HIV infection among the inner city commuter population in Johannesburg, South Africa Keith Muloongoa, Ndumiso Tshumaa, Lucy Chimoyib, Geoffrey Setswec, Bismark Sarfoe and Peter Nyasulud,f,*
*Corresponding author: Present address: School of Health Sciences, Monash University, South Africa. Tel: +27 11 950 4287; E-mail: [email protected]
Received 14 March 2014; revised 26 June 2014; accepted 27 June 2014 Background: The study aimed to determine factors contributing to the acceptability of home-based HIV counselling and testing (HBHCT) among commuters in Johannesburg inner city. Methods: Simple random sampling was used to select participants in a venue based intercept survey at Noord Street taxi rank in Johannesburg central business district. A total of 1146 individuals were interviewed and logistic regression analysis assessed factors associated with HBHCT acceptability. Results: HBHCT acceptability was 64%. Home testing was preferred as an alternative to testing at a health facility. High school education (adjusted odds ratio [aOR] 0.61, CI 0.46–0.85), inner city residence aOR 0.70, CI 0.52–0.94), previous HIV testing in the hospital (aOR 0.22, CI 0.15–0.32) and at home (aOR 0.18, CI 0.11–0.27) were significantly less likely associated with HBHCT acceptability. Being married (aOR 1.64, CI 1.15–2.32), recent HIV testing (aOR 1.85, CI 1.15–2.99) and having experienced negative health worker attitude (aOR 2.41, CI 1.66–3.48) were significantly more likely associated with HBHCT acceptability. Conclusions: High acceptability of HBHCT among urban-based commuters plus factors that would deter HBHCT acceptability were identified. Further research to identify strategies to improve HBHCT acceptability among commuter populations is needed. Keywords: Commuter population, Counselling, HIV, HIV testing, Home-based testing, Johannesburg
Introduction Worldwide, more than 35 million people now live with HIV/AIDS, 3.3 million of whom are under the age of 15. In 2012, an estimated 2.3 million people were newly infected with HIV and 260 000 of these were under the age of 15. Every day, nearly 6300 people contract HIV: approx. 262 every hour. Since the beginning of the epidemic, more than 75 million people have contracted HIV and nearly 36 million have died of HIV-related causes.1 More than 70% (25 million) of people living with HIV live in sub-Saharan Africa including 88% of the world’s HIV-infected children. In 2012, an estimated 1.6 million people in the region became newly infected. An estimated 1.2 million adults and children died of AIDS, accounting for 75% of the world’s AIDS deaths in 2012.1 The estimated overall HIV prevalence rate in South Africa
is approximately 10% representing the highest in the world. Among adults aged 15–49 years, an estimated 15.9% of the population are living with HIV.2 The estimated prevalence of HIV in Gauteng is 16.5% which is higher than the national estimate. Out of the 12 272 263 people living in Gauteng only 1 447 200 (11.8%) individuals received HIV counselling and testing (HCT).3 In this context, it is clear that HIV is still a very important infection that must be controlled and prevented in subSaharan Africa and more especially in South Africa. In the past, a lot of resources have been put into stemming the tide of HIV with some noticeable achievements. Donor fatigue and dwindling resources call for a re-look at every opportunity not only to advance an increase in HCT uptake but also to focus on key at-risk populations within the society that can benefit from HCT services.
# The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: [email protected].
632
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
a Community AIDS Response, Norwood, Johannesburg, South Africa; bWits Reproductive Health and HIV Research Institute (WHRI), Hillbrow, Johannesburg, South Africa; cHIV/AIDS, STI and TB (HAST) Research Program, Human Sciences Research Council Pretoria, South Africa; dSchool of Public Health, University of the Witwatersrand, Johannesburg, South Africa; eDepartment of Epidemiology and Disease Control, School of Public Health, University of Ghana, Legon-Accra, Ghana; fSchool of Health Sciences, Monash University, Ruimsig, Johannesburg, South Africa
Transactions of the Royal Society of Tropical Medicine and Hygiene
treatment and care efforts although they are most often difficult to reach due to their mobility, leaving HCT service providers with no option but to intercept them in open public places such as taxi ranks, bus and train stations. The goal was to find out whether such populations could easily be accessed through the HBHCT approach.
Methods Study design The study used a simple random sampling technique to select participants in a venue based intercept survey at the four corners of Noord Street taxi rank in Johannesburg inner city central business district (CBD). The simple random technique entailed the selection of an even number from a bowl with numbers one to ten. Field workers approached potential participants walking towards the corners that served as intercept points and sought verbal consent prior to allowing potential participants to pick the numbers from a bowl. Only those who picked an even number were allowed to respond to a closed ended questionnaire.
Study setting The Noord Street taxi rank is by far the largest and busiest in Johannesburg and is positioned at the heart of the inner city in the CBD.14 During apartheid, the CBD was Johannesburg’s commercial centre, home to many of the city’s national and international companies. Following the fall of apartheid, the CBD made a swift and disorderly transition, absorbing many of the urban poor while a majority of businesses and corporations fled to upper class suburbs such as Sandton. Individuals came to the inner city from townships, which were inconveniently far from businesses, for cheaper transportation, job opportunities and more convenient access to social amenities. The CBD also saw a large influx of individuals from other provinces and neighbouring countries.15 The 2011 census reported that Gauteng province absorbed a net migration of 1 037 871 individuals between 2001 and 2011, the highest in the country.16 As a result, the CBD has transformed from a spacious, well-maintained business district, to a densely populated, culturally diverse, and poorly regulated city centre over a short period of time.15 The taxi rank is Johannesburg’s primary transit centre for all vehicles operating in South Africa’s mini-taxi system. It is common knowledge that taking a mini-taxi is often inconvenient and time consuming, but is also the most cost effective way of getting from one part of the city to another. Therefore, the minitaxi system is primarily utilised by individuals without the means to afford more comfortable and convenient modes of transport such as private cars or metered taxis. Most passengers use the Noord taxi rank as a platform to start their commute or switch directions and travel to a different area of the city. Individuals moving through the Noord taxi rank come from townships at the city periphery, and from the CBD itself. The CBD has high levels of unemployment and is adjusting to relatively new increased population densities. Often, the only tangible housing options for individuals living in the CBD are illegal, informal renting spaces, which often operate out of dilapidated buildings. It is estimated that 100 000 of the city’s residents utilise informal rental housing
633
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
Bateganya et al.4 reiterated that low uptake of HIV voluntary counselling and testing (VCT) is one of the HIV prevention intervention strategies that may have hindered global attempts to prevent new HIV infections. It might also have limited the scale-up of HIV care and treatment to infected persons. In this HIV epidemic era, a renewed focus seems to have shifted towards prevention efforts thereby making VCT a priority intervention. For that reason, there is a need to focus on methods that would ultimately increase the uptake of HCT. As a result of this emphasis, home based HCT (HBHCT) delivery models may be an effective avenue to enhance uptake of HCT among individuals in the communities. Such an approach might lead to an improvement in HIV/AIDS patients’ access to early treatment, and also prevent occurrence of new infections.4–6 Scale up of HCT uptake may not only enhance early detection of HIV infection, but also could be a mode of facilitating opportunity to early treatment, care and support for those who are infected. HBHCT offers the opportunity to improve VCT uptake as long as government policy to implement such an approach is promulgated. Individuals advocating for HBHCT have forecast increasing rates of home testing among individuals in various communities.5–7 Since HBHCT appears an easier program to execute,8 we share the opinion that availability of rapid home HIV test kits will dramatically scale up rates of HIV detection among communities and hard-to-reach populations. Despite the notion that no evidence exists, large-scale door-to-door testing has shown feasibility in resource-poor settings that experiences significant stigma surrounding HIV/AIDS.9,10 The concept of HBHCT is not new. However, full involvement of community care workers, commonly known as caregivers, entrusted with the responsibility to provide this service by the Department of Health in South Africa has not yet taken place. It is fully established and generally accepted that HCT is a critical gateway for addressing HIV prevention as it provides a way of linking people to treatment, care and support. Hence there is growing interest in expanding HIV testing coverage through the implementation of innovative models such as HBHCT.7 There are two studies on HBHCT that have been conducted in South Africa, namely: ‘Modelling the effectiveness of combination prevention from a house-to-house HIV testing platform in Kwazulu-Natal, South Africa’11 and ‘Client characteristics and acceptability of a home-based HIV counselling and testing intervention in rural South Africa’.7 Both of these studies were done in rural settings of KwaZulu-Natal province. Similar studies have also been conducted in Uganda,12 Kenya,6,10 Zambia5 and one global systematic review.13 The target populations for these studies were community members in urban and/or rural settings. One of the Kenyan studies used a mixed methods design while the rest were all quantitative. None of them focused on commuter populations which are groups of people who travel some distance to and from work or in search of work on a regular basis. These are a critical group of people for whom it is difficult to offer health services because they leave their homes early in the morning and come back late at night and yet they form an important group not to be ignored in the fight against HIV transmission. Evidently, no studies of this nature have been done in Gauteng province. This study therefore sought to understand the factors contributing to acceptability of rapid testing in homes among the commuter population in the inner city of Johannesburg. Commuter populations are key target groups for HCT, prevention,
K. Muloongo et al.
in the inner city.14 The Noord Street taxi rank though with such a bustling number of commuters has had limited health intervention studies undertaken.
Data collection
Results Frequency distribution of study characteristics according to gender
Data were collected using an electronic questionnaire loaded in Tablet personal computers during a two-day HCT campaign at the taxi rank in May 2013. The fieldworkers interviewed participants and recorded responses directly into Tablets. This followed a community outreach campaign organised in conjunction with the Department of Health which targeted taxi ranks in the Johannesburg Metropolitan health district. The measures used for data collection were categorised into socio-demographic characteristics, history of testing and barriers to testing. Socio-demographic characteristics included participant age (under 15, 15–19, 20–24 and 25–35 years), marital status (single, married, divorced, cohabitating), occupation (formally employed, self-employed, student, not employed), education (below high school level, high school level, tertiary qualification which included certificate, diploma and degree), distance to the nearest clinic (0–10, 11–20, 21–30, .30 km), place of residence (inner city and outside inner city) and place of work (inner city and outside inner city). HIV testing history included the most recent time the participant had tested for HIV under the categories, ,1 year, 1–2 years and ≥3 years; persons with no prior HIV test comprised the reference group. The participants were also asked the total number of times they had tested in the previous year and were categorised as 0, 1, 2, 3, 4, 5, 6 or never. The barriers to HIV testing were categorised as emotional and cognitive, social, economic and structural. The participants who had tested and not tested for HIV in the past were asked to identify the obstacles to testing for HIV. Home testing and mobile outreach facilities were combined to form one variable used as the outcome for analysis.
Among participants who preferred home testing, 59.0% of 732 (n¼432) had their HIV test less than a year ago compared with only 50.0% of 414 (n¼207) among participants who did not prefer home testing and had their HIV test less than a year ago. Approximately 83% (82.5%, n¼522) of those who previously visited a clinic for HIV testing preferred taking subsequent tests at home and this proportion was significantly higher than those who previously visited a clinic for HIV testing but did not prefer HBHCT (49.0%, n¼179, p¼0.0001). Participants who preferred HBHCT cited health worker attitudes as one of the major barriers to HIV testing (27.9%, n¼204, p,0.001). The majority of the participants surveyed had knowledge of HCT, were living together with people with HIV/AIDS, had family members with HIV/AIDS and knew people who had died as a result of an HIV/AIDS related illness (Table 2).
Statistical analysis
Unadjusted factors associated with home-based HIV counselling and testing
Statistical analysis was performed using STATA software version 1217 and included descriptive, bivariate and inferential procedures. Descriptive analyses looked at the frequencies of selected responses given by participants. Differences among male and female participants were evaluated by x2 test. This was also performed to examine differences in the outcome with selected variables. Univariate logistic regression analysis were performed to assess the relationship between each variable construct and the outcome. Variables in univariate analysis with a p,0.05 were included in the multivariate analysis. Multiple logistic regression analysis was performed, considering the acceptability of home testing variable as a dependent variable and all the sociodemographic and HIV testing factors as independent variables. A forward selection procedure was applied. Variables with a p,0.05 were deemed statistically significant and were included in the multivariate model. The multiple logistic regression models were constructed to adjust for the confounding effect age and place of residence. The final model presented the ORs and their corresponding 95% CIs.
Factors associated with HBHCT between socio-demographic and HIV testing related choices were assessed in the univariate logistic regression model. Being married was positively associated with HBHCT acceptability compared with being single (OR 1.58, 95% CI 1.19–2.11). Those with a secondary school education were 25% less likely to prefer HBHCT compared with those without (OR 0.75, 95% CI 0.56–1.00). Participants living 11–20 km (OR 0.61, 95% CI 0.44–0.85) and more than 30 km (OR 0.73, 95% CI 0.25–0.56) away from the nearest health facility were less likely to prefer HBHCT compared with those living near the clinic. Residing (OR 0.69, 95% CI 0.54–0.88) in the inner city and working (OR 0.59, 95% CI 0.54–0.89) outside the inner city were less likely associated with HBHCT acceptability than residing within the inner city. Participants who had an HIV test less than a year ago were 65% more likely to be associated with HBHCT compared with those who never tested (OR 1.65, 95% CI 1.20–2.25). Participants who previously had an HIV test at a hospital (OR 0.24, 95% CI 0.17–0.34) or a home/mobile outreach facility (OR 0.16, 95% CI 0.10–1.23) were less likely to be associated with
634
Characteristics of HIV testing practices according to home testing preferences
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
Out of the 1146 participants, 49.5% were male (n¼567) while 50.5% were female (n¼579). The majority (42.1%, n¼483) of the participants were in the age group 20–24 years. Most of the participants were single (69.9%, n¼801) showing more single female participants (75.1%, n¼435) compared to their male counterparts (64.6%, n¼366). Nearly two-fifths of the female and male participants were unemployed (37.3%, n¼216, females and 39.7%, n¼225, males) respectively. More women (50.7%, n¼294) had a high school qualification compared with men (36.0%, n¼204). Slightly, above half of the participants resided and were employed in the inner city. The majority of the participants (63.9%, n¼732) preferred a rapid test (HBHCT) performed at their homes (61.7%, n¼357 females and 66.1%, n¼375 males) respectively (Table 1).
Transactions of the Royal Society of Tropical Medicine and Hygiene
Table 1. Frequency distribution of demographic characteristics according to gender
Table 2. Comparison of frequency distribution of HIV testing practices according to home testing preferences
Characteristics
Characteristics
Female n¼579 n (%)
p-value
Does not prefer home testing n (%)
Prefers home testing n (%)
p-value
123 (16.8) 432 (59.0) 105 (14.3) 15 (2.1) 57 (7.8)
0.002
522 (82.5) 69 (10.9) 42 (6.6)
,0.0001
570 (77.9) 162 (22.1)
NS
492 (67.2) 240 (32.8)
NS
393 (53.7) 339 (46.3)
NS
444 (60.7) 288 (39.3)
NS
210 (28.7) 204 (27.9)
,0.0001
0.009 36 (6.4) 126 (22.2) 264 (46.6) 141 (24.9) 0.018 366 (64.6) 6 (1.1) 186 (32.8) 9 (1.6) NS 108 (19.1) 183 (32.3) 225 (39.7) 51 (8.9) 0.007 186 (32.8) 204 (36.0) 177 (31.2) ,0.0001 426 (75.1) 66 (11.6) 18 (3.2) 57 (10.1) 0.002 324 (57.1) 243 (42.9) 0.003 345 (60.9) 222 (39.2) NS 375 (66.1) 192 (33.9)
NS: not significant.
HBHCT compared with those who previously tested in a clinic. Lastly participants who experienced a negative health worker’s attitude were 59% more likely to prefer HBHCT than those who did not have such an experience (OR 1.59, 95% CI 1.11–2.28). Lack of confidentiality in the home as a potential hindrance to HBHCT was less likely associated with HBHCT acceptability (OR 0.55, 95% CI 0.39–0.76) (Table 3).
Adjusted factors associated with home-based HIV counselling and testing In the adjusted logistic regression analysis, being in the age-group 25–35 years (aOR 0.48, CI 0.34–0.67), having secondary school education (aOR 0.61, CI 0.46–0.85), residing in the inner city
Last HIV test Never tested 97 (23.4) ,1 year 207 (50.0) 1–2 years 54 (13.0) 2–3 years 5 (1.2) .3 years 51 (12.3) Place of previous HIV test Clinic 179 (48.3) Hospital 96 (26.7) Home/mobile 90 (25.0) outreach Knowledge of HCT centres Yes 336 (81.2) No 78 (18.8) Knowledge of persons with HIV Yes 282 (68.1) No 132 (31.9) Knowledge of family members with HIV Yes 231 (55.8) No 183 (44.2) Knowledge of HIV-related deaths Yes 255 (61.6) No 159 (38.4) HIV testing barriers None 108 (26.1) Health worker 66 (15.9) attitudes Difficulty in 48 (11.6) accessing services Lack of ART 21 (5.1) Lack of 135 (22.6) confidentiality Presence of fee for 30 (7.3) HIV testing Others 6 (1.5)
84 (11.5) 33 (4.5) 144 (19.7) 45 (6.1) 12 (1.6)
ART: antiretroviral therapy; HCT: HIV counselling and testing; NS: not significant.
(aOR 0.70, CI 0.52–0.94), visiting a hospital (aOR 0.22, CI 0.15– 0.32) and testing at home or mobile outreach (aOR 0.18, CI 0.11–0.27) were significantly less likely to be associated with HBHCT acceptability. Being married (aOR 1.64, CI 1.15–2.32), having tested less than a year ago (aOR 2.03, CI 1.41–2.93) or between 1–2 years ago (aOR 1.85, CI 1.15–2.99) and experiencing negative attitudes from health workers (aOR 2.41, CI 1.66–3.48) were significantly more likely to be associated with HBHCT acceptability (Table 3).
635
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
Age group ,15 years 69 (11.9) 15–19 years 135 (23.3) 20–24 years 219 (37.8) 25–35 years 156 (26.9) Marital status Single 435 (75.1) Cohabiting 12 (2.1) Married 117 (20.2) Divorced 15 (2.6) Occupation Unemployed 216 (37.3) Self employed 129 (22.3) Formally employed 135 (23.3) Student 99 (17.1) Education level Below high school 138 (23.8) High school 294 (50.8) Tertiary 147 (25.4) Distance to nearest clinic 0–10 km 366 (63.2) 11–20 km 114 (19.7) 21–30 km 48 (8.3) .30 km 51 (8.8) Place of residence Inner city 333 (57.5) Outside inner city 246 (42.5) Area of employment Inner city 360 (62.2) Outside inner city 219 (37.8) Home testing preference Yes 357 (61.7) No 222 (38.3)
Male n¼567 n (%)
K. Muloongo et al.
Table 3. Univariate and multivariate analysis of factors associated with home-based HIV testing Factor
Unadjusted OR (95% CI)
p–value
OR (95% CI)
p–value
1.00 1.22 (0.76–1.98) 0.95 (0.61–1.48) 0.68 (0.43–1.08)
0.411 0.828 0.102
1.00 ND ND 0.48 (0.34–0.67)
NA NA ,0.0001
1.00 1.28 (0.47–3.43) 1.58 (1.19–2.11) 1.06 (0.46–2.46)
0.629 0.002 0.886
1.00 ND 1.64 (1.15–2.32) ND
NA 0.006 NA
1.00 0.75 (0.56–1.00) 1.18 (0.85–1.65)
0.054 0.314
1.00 0.61 (0.46–0.85) ND
,0.0001 NA
1.00 0.61 (0.44–0.85) 0.82 (0.48–1.38) 0.73 (0.25–0.56)
0.003 0.45 ,0.0001
1.00 ND ND ND
NA NA NA
1.00 0.69 (0.54–0.88)
0.003
1.00 0.70 (0.52–0.94)
0.017
1.00 0.69 (0.59–0.89)
0.003
1.00 ND
NA
1.00 1.65 (1.20–2.25) 1.53 (1.00–2.34) 2.37 (0.83–6.74) 0.88 (0.56–1.40)
0.002 0.047 0.107 0.592
1.00 2.03 (1.41–2.93) 1.85 (1.15–2.99) ND ND
,0.0001 0.012 NA NA
1.00 0.24 (0.17–0.34) 0.16 (0.10–1.23)
,0.0001 ,0.0001
1.00 0.22 (0.15–0.32) 0.18 (0.11–0.27)
,0.0001 ,0.0001
1.00 1.59 (1.11–2.28) 0.90 (0.59–1.38) 0.81 (0.45–1.46) 0.55 (0.39–0.76) 0.77 (0.46–1.29) 1.03 (0.38–2.82)
0.012 0.626 0.482 ,0.0001 0.325 0.965
1.00 2.41 (1.66–3.48) ND ND ND ND ND
,0.0001 NA NA NA NA NA
NA: not applicable; ND: not detected.
Discussion There is growing interest in the expansion of HIV testing services through the implementation of innovative models such as the
636
HBHCT7 in order to link people to treatment, care and support. Although some studies have been conducted on HBHCT,7,10,11,13,14 none of them focused on the commuter population, which constitutes a critical group of people who are key to
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
Age group ,15 years 15–19 years 20–24 years 25–35 years Marital status Single Cohabiting Married Divorced Education level Below high school High school Tertiary Distance to nearest clinic 0–10 km 11–20 km 21–30 km .30 km Place of residence Inner city Outside inner city Area of employment Inner city Outside inner city Last HIV test Never tested ,1 year 1–2 years 2–3 years .3 years Place of previous HIV test Clinic Hospital Home/mobile outreach HIV testing barriers None Health worker attitudes Difficulty in accessing services Lack of antiretroviral therapy Lack of confidentiality Presence of HIV testing fee Other factors
Adjusted
Transactions of the Royal Society of Tropical Medicine and Hygiene
think about it, knowing ones HIV status, being HIV-positive and not feeling at risk of having or acquiring HIV7 which are different to the factors that our study exposes. Our study, which was based in a typical urban setting, highlights statistically significant factors associated with HBHCT as being married, having tested less than one year ago and having experienced negative health worker attitudes at health facilities. Each time these factors are encountered we should bear in mind that the chances of HBHCT preference are more likely going to be promulgated. Factors less likely associated with HBHCT have shown to be issues to do with levels of education, residing more than 10 km from the nearest health facility and taking an HIV test at a hospital as opposed to a clinic. We observed that more participants (522 vs 179) who had their previous HIV test at a clinic preferred home testing, while more of those who preferred home testing (204 vs 66) expressed poor health worker attitudes as a main reason for their choice. Whereas poor health worker attitude drives away a significant number from testing in the clinics, it creates an opportunity for a parallel intervention using HBHCT approach. This study supports the findings of a study done in Tanzania in which married couples idealised testing at home as a way of strengthening and deepening their marital relationship, because it provided an opportunity to reflect upon fundamental values and priorities in a relationship.21 An HBHCT will allow people to test when they want to and how they want to, in the privacy of their own homes. This will allow a whole new population of people to know their HIV status without having to go to a local testing centre. Having an HIV test openly and easily available might also reduce the stigma surrounding both the illness and getting tested for it. However, a disadvantage of HBHCT is that a person could be identified as having tested for HIV if the HBHCT care givers visit homes in neighbourhoods where they are known. But this could be avoided if the care givers work in more distant locations with less familiar personnel. Recently, the USA Food and Drug Administration (FDA) approved a home-based HIV testing kit called OraQuick which underscores the need to embrace home-based testing, especially by countries in sub-Saharan Africa. The major characteristic and advantage of this study was the direct access it provided to targeted commuter populations making it easier and cost-effective because survey field workers readily reached a large number of commuters. In spite of these advantages, there were some limitations to be noted. The main limitations of the study were ‘information bias’ resulting from differential recall among study participants as some of them had tested for HIV more than a year prior to the survey. Other limitations include: lack of generalizability of the study results as potential participants who were randomly approached and declined to respond to the questionnaire for one reason or another may have influenced a non-response error whereby we could not be sure that those who responded were not in some way different from those that chose not to respond; social desirability bias would have occurred due to the sensitive nature of HIV information as the survey was done in an open, public place; and lastly, venuebased intercept surveys that are too lengthy and/or complex to be completed owing to skips, branching, or other complexities prove challenging to administer. However none of these issues were encountered in this study.
637
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
the transmission of HIV. The provision of HBHCT will ensure that clients receive HIV test results quickly and will serve as a means to identify first time testers who would not have visited a health facility to test for HIV. This model of HBHCT will also allow for the utilisation of lay counsellors and community based health workers in order to decongest the health facilities and reduce the disease burden. HBHCT will provide the opportunity to test couples and/or the entire family in one household. However HBHCT poses challenges such as counsellor fatigue, safety and security in the inner city, partner violence and abuse, lack of confidentiality among family members, consent and refusal issues.18 This is one of the first studies in South Africa to report on acceptability of HBHCT among a commuter population using urban public transport system. The results show an overall acceptability level of 64%. This is slightly lower than 69% of participants in the home based HCT cluster randomised controlled trial conducted in rural South Africa,19 and 76.1% of those who indicated their willingness to be HIV tested following the home-based HCT delivery process in urban and rural population in Zambia. Acceptability did not differ by sex but was higher in the rural compared with urban areas (83.6% vs 70.7%). 5 This shows that acceptability of HBHCT uptake seems to be higher in rural settings as opposed to urban settings. Therefore, there is a need to enhance HCT intervention efforts through advocacy, communication and social mobilization in this setting. In this study 68% of the participants lived within 10 km of a health facility. The assumption was that the commuter population would prefer open spaces such as taxi ranks for testing and not testing in their homes. According to this study, testing at home is better than testing at a health facility among commuter population. The majority of participants cited health worker attitude as a reason for deciding to test at home. The implication for this choice is that health facilities need to study the kinds of health worker attitudes necessary to draw commuter populations or indeed any other HCT seekers to health facilities. Any improvement initiatives should take into account the factors necessary to attract ‘the would-be testers’ to health facilities. A Zambian study that randomised community clusters to HCT either at a local clinic or at an optional location (most commonly the home) found an almost five-fold increase in counselling and testing in the optional location group.20 In our study health facility HCT visit experience had a negative influence as about 83% of those who previously visited a health facility subsequently preferred home testing. This creates an opportunity to supplement efforts that would increase HCT uptake by taking a home-based approach to offering HCT. This can be done through community health workers providing HCT in addition to other health related services such as screening for TB and home-based care provided to the HIV positive individual as well as targeting other members of the household for HCT services.18 It is most important to better understand the correlates of HIV testing in order to ensure that HIV prevention programmes and HCT outreach actively promotes HIV testing among this commuter population. A study on client characteristics and acceptability of an HBHCT intervention in rural South Africa found that the most common reasons for not testing were, among others: not being ready/feeling scared/needing to
K. Muloongo et al.
Conclusions
7 Naik R, Tabana H, Doherty T et al. Client characteristics and acceptability of a home-based HIV counselling and testing intervention in rural South Africa. BMC Public Health 2012;12:824. 8 Walensky RP, Paltiel AD. Rapid HIV testing at home: does it solve a problem or create one? Ann Intern Med 2006;145:459–62. 9 Kimaiyo S, Were MC, Shen C et al. Home-based HIV counselling and testing in western Kenya. East Afr Med J 2010;87:100–8. 10 Low C, Pop-Eleches C, Rono W et al. The effects of home-based HIV counseling and testing on HIV/AIDS stigma among individuals and community leaders in western Kenya: Evidence from a cluster-randomized trial. AIDS Care 2013;25:97–107. 11 Alsallaq R, Baeten J, Hughes J et al. Modelling the effectiveness of combination prevention from a house-to-house HIV testing platform in Kwazulu Natal, South Africa, Sex Transm Infect 2011;87:A36.
Authors’ contributions: KM, NT and PN designed the research while KM and NT conducted research.KM, NT, GS, BS, PN and provided essential constructs for the writing of the manuscript. LC performed statistical analysis; KM, NT, GS, LC and PN wrote the paper. All authors read and approved the final version of the manuscript. PN is guarantor of the paper.
12 Sekandi JN, Sempeera H, List J et al. High acceptance of home-based HIV counseling and testing in an urban community setting in Uganda. BMC Public Health, 2011;11:26–9.
Funding: CARE International South Africa-Lesotho office provided funding for the primary data collection.
14 City of Johannesburg. Taxis. 2014 Official website of the City of Johannesburg. www.joburg.org.za/index.php?option=com_content &id=60. [accessed 27 January 2014].
Competing interests: None declared.
15 Ayala A, Geurts E, Ahmad P et al. Urbanising Africa: the city centre revisited. Experiences with inner-city revitalization from Johannesburg (South Africa), Mbabane (Swaziland), Lusaka (Zambia), Harare and Bulawayo (Zimbabwe). Rotterdam: Institute for Housing and Urban Development Studies. IHS Working Papers Series no. 26/2010.
Ethical approval: Approval to use data for this study was obtained from Community AIDS Response (CARe). Informed consent from individual participants was obtained at the time of primary data collection, no participant identifiers were obtained.
References 1 amfAR. Statistics: Worldwide. New York: The Foundation for AIDS Research; 2013. http://www.amfar.org/about-hiv-and-aids/factsand-stats/statistics--worldwide/ [accessed 14 June 2014]. 2 Statistics South Africa. Mid-year population estimates: 2013. Statistical release P0302. Pretoria: Statistics South Africa; 2013. http://beta2.statssa. gov.za/publications/P0302/P03022013.pdf [accessed 8 May 2014]. 3 PEPFAR Gauteng. Partnership to Fight HIV/AIDS in South Africa. Washington, DC: Office of the Global AIDS Coordinator; 2010. http:// www.pepfar.gov/countries/southafrica/ [accessed 15 June 2014]. 4 Bateganya MH, Abdulwadud OA, Kiene SM. Home-based HIV voluntary counseling and testing in developing countries. Cochrane Database Syst Rev 2009;4:CD006493. 5 Mutale W, Michelo C, Ju¨rgensen et al. Home-based voluntary HIV counselling and testing found highly acceptable and to reduce inequalities. BMC Public Health 2010;10:347.
638
13 Suthar AB, Ford N, Bachanas PJ et al. Towards universal voluntary HIV testing and counselling: a systematic review and meta-analysis of community-based approaches. PLoS Med 2013;10:8:e1001496.
16 Statistics South Africa. Census 2011. Statistical Release (Revised) P0301.4. Pretoria: Statistics South Africa; 2012. http://www.statssa. gov.za/publications/P03014/P030142011.pdf [accessed 25 February 2014]. 17 StataCorp. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP; 2013. 18 Taegtmeyer M, Blazer C, Escobar MC et al. Out of the clinic and into the home. Development of WHO/PEPFAR Home-Based HIV Testing and Counseling Support Tools. http://pag.aids2012.org/EPosterHandler. axd?aid=7082 [accessed 14 June 2014]. 19 Doherty T, Tabana H, Jackson D et al. Effect of home based HIV counselling and testing intervention in rural South Africa: cluster randomised trial. BMJ 2013;346:3481. 20 Fylkesnes K, Siziya S. A randomized trial on acceptability of voluntary HIV counselling and testing. Trop Med Int Health 2004;9:566–72. 21 Njau B, Watt MH, Ostermann J et al. Perceived acceptability of home-based couples voluntary HIV counseling and testing in Northern Tanzania. AIDS Care 2012;24:413–9.
Downloaded from http://trstmh.oxfordjournals.org/ at Mount Allison University on June 11, 2015
The findings of this study indicate that HBHCT is acceptable among the urban-based commuter population in the inner city of Johannesburg. The study has also identified factors that would impact negatively on HBHCT acceptability among this key population. However, future HBHCT programmes should consider using existing urban infrastructure such as taxi ranks to develop strategies to reach a broader range of clients, and tailor HIV prevention intervention approaches and services to meet the unique needs of commuter populations. In view of the factors observed that would hinder HBHCT, we suggest training of health workers to improve client relations, use of trained lay counsellors, free HCT services and taking HCT to homes to enhance HCT uptake among commuter populations.
6 Negin J, Wariero J, Mutuo et al. Feasibility, acceptability and cost of home-based HIV testing in rural Kenya. Trop Med Int Health. 2009;14:849–55.
