The Feasibility of Community-Based VCT

in Zimbabwe

The Feasibility of Community-Based VCT

in Zimbabwe

Gertrude Khumalo-Sakutukwa and Steve MorinGertrude Khumalo-Sakutukwa and Steve Morin

AIDS Policy Research CenterAIDS Policy Research Center

AIDS Research InstituteAIDS Research Institute

University of California, San FranciscoUniversity of California, San Francisco

BackgroundBackground

Most HIV infections are in sub-Saharan Africa, yet Most HIV infections are in sub-Saharan Africa, yet only a small fraction of Africans know their HIV only a small fraction of Africans know their HIV status. status.

Voluntary HIV Counseling and Testing (VCT) is an Voluntary HIV Counseling and Testing (VCT) is an effective method of promoting behavior change, effective method of promoting behavior change, but utilization of VCT is still low in African but utilization of VCT is still low in African communities with a high prevalence of HIV. communities with a high prevalence of HIV.

Zimbabwe

Harare

~25% of sexually active Zimbabwean adults are infected with HIV, yet only a small percentage know their HIV status

Access to VCTAccess to VCT

10% know their HIV status10% know their HIV status

Limited VCT servicesLimited VCT services

VCT uptake low VCT uptake low

Diagnostic HIV testing in hospitals & private Diagnostic HIV testing in hospitals & private sectorsector

PMTCT-VCT (mums & babies)-nationalPMTCT-VCT (mums & babies)-national

14 VCT sites - PSI/USAID/Zim-MOH14 VCT sites - PSI/USAID/Zim-MOH

Community-Based VCTCommunity-Based VCT

Intervention has three major strategies: Intervention has three major strategies:

to make VCT more available in community settingsto make VCT more available in community settings

to engage the community through outreach; and to engage the community through outreach; and

to provide post-test support. to provide post-test support.

These three strategies are designed to change These three strategies are designed to change community norms and reduce risk for HIV infection community norms and reduce risk for HIV infection among all community members, irrespective of whether among all community members, irrespective of whether they participated directly in the intervention. they participated directly in the intervention.

Aim 1: AcceptabilityAim 1: Acceptability

Aim:Aim: To assess acceptability of Mobile VCT To assess acceptability of Mobile VCT (MVCT) in two communities (MVCT) in two communities

Method:Method: A mobile caravan provided free, A mobile caravan provided free, anonymous VCT in 12 market areas, visiting the anonymous VCT in 12 market areas, visiting the sites on a rotating basis for one week, using two sites on a rotating basis for one week, using two rapid HIV tests (Unigold and Determine) rapid HIV tests (Unigold and Determine)

Sample:Sample: 1101 adults who completed VCT at the 1101 adults who completed VCT at the community-based sitescommunity-based sites

The road to market in EpworthThe road to market in Epworth

Setting up the caravan for VCT at the Solani Marketplace in Epworth

“Plan for Tomorrow -- Get HIV Tested Today”

ResultsResults 99% of participants chose to receive their results 99% of participants chose to receive their results

on the same day. on the same day.

No adverse outcomes (acts of discrimination or No adverse outcomes (acts of discrimination or physical violence) were observed or reported.physical violence) were observed or reported.

32% of testers were under 26, and 70% were under 32% of testers were under 26, and 70% were under 31. More men (58%) than women (42%) tested. 31. More men (58%) than women (42%) tested.

HIV prevalence was 29%, higher than the figure HIV prevalence was 29%, higher than the figure reported among clients of fixed-site testing centers reported among clients of fixed-site testing centers in Harare of approximately 17%.in Harare of approximately 17%.

Aim 2: Predictors of TestingAim 2: Predictors of Testing Aim:Aim: To assess predictors of mobile testing To assess predictors of mobile testing

Method:Method: Questionnaires were administered in Questionnaires were administered in face-to-face interviews regarding knowledge of face-to-face interviews regarding knowledge of HIV, use of Mobile VCT, risk behaviors and HIV, use of Mobile VCT, risk behaviors and demographicsdemographics

Sample:Sample: 483 testers at the Mobile VCT sites and 483 testers at the Mobile VCT sites and 332 individuals who did not access VCT at the 332 individuals who did not access VCT at the same sites (non-testers)same sites (non-testers)

Women deciding whether to test

On the scene with mobile VCT …

Reasons for No Prior Testing Reasons for No Prior Testing

N/TotalN/Total %Yes%Yes

Hours are not convenientHours are not convenient 89/34889/348 25.6%25.6%

Location is not convenientLocation is not convenient 72/34872/348 20.7%20.7%

Cost is too highCost is too high 28/35028/350 8.0%8.0%

Concern about confidentialityConcern about confidentiality 7/3507/350 2.0%2.0%

Don’t trust the result will be correctDon’t trust the result will be correct 1/3451/345 0.3%0.3%

Embarrassed to be seen at testing centerEmbarrassed to be seen at testing center 0/3430/343 0%0%

Predictors of HIV TestingPredictors of HIV Testing

Being at increased risk of HIV infection, Being at increased risk of HIV infection, i.e., reporting “feel at increased risk” i.e., reporting “feel at increased risk” (p<.001); (p<.001);

reporting one or more STIs (p,.001); and reporting one or more STIs (p,.001); and

not using condoms in last 3 months not using condoms in last 3 months (p<.01)(p<.01)

Aim 3: Views About TestingAim 3: Views About Testing Aim:Aim: To explore beneficial or adverse outcomes of To explore beneficial or adverse outcomes of

Mobile VCT Mobile VCT

Method:Method: In-depth interviews with testers and non- In-depth interviews with testers and non-testers to determine knowledge of HIV, factors testers to determine knowledge of HIV, factors determining the use of Mobile VCT and determining the use of Mobile VCT and preferences regarding programmatic optionspreferences regarding programmatic options

Sample:Sample: 30 testers at the Mobile VCT sites and 29 30 testers at the Mobile VCT sites and 29 individuals declining VCT at the same sites (non-individuals declining VCT at the same sites (non-testers)testers)

Counselors and outreach worker ready for action

Motivations to testMotivations to test

Motivations to test included Motivations to test included concern about physical symptoms of illness concern about physical symptoms of illness the death or illness of a family member or the death or illness of a family member or

friendfriend perceived risk of HIV infectionperceived risk of HIV infection

Barriers to TestingBarriers to Testing Structural barriers to testing included expense Structural barriers to testing included expense

and travel timeand travel time

Psychological barriers included fear that a Psychological barriers included fear that a positive result would lead to emotional distress positive result would lead to emotional distress and physical symptoms such as weight loss or and physical symptoms such as weight loss or illnessillness

Testers reported that mobile VCT removed Testers reported that mobile VCT removed structural barriers, allowing individuals to structural barriers, allowing individuals to confront psychological barriersconfront psychological barriers

Overcoming BarriersOvercoming Barriers

Testers reported that discussions with mobile VCT Testers reported that discussions with mobile VCT staff and outreach workers helped them overcome staff and outreach workers helped them overcome psychological barrierspsychological barriers

28 of 29 testers reported having recommended 28 of 29 testers reported having recommended VCT to family members or friendsVCT to family members or friends

Stigma was not cited as a primary reason for Stigma was not cited as a primary reason for declining testing by any non-testersdeclining testing by any non-testers

Both testers and non-testers believed mobile VCT Both testers and non-testers believed mobile VCT was beneficial to their communitieswas beneficial to their communities

ConclusionsConclusions

Barriers to HIV testing in Sub-Saharan Africa are Barriers to HIV testing in Sub-Saharan Africa are often logistical and can be overcome through often logistical and can be overcome through community-based strategies. community-based strategies.

Same day testing in a community setting is Same day testing in a community setting is acceptable and attracts individuals at increased acceptable and attracts individuals at increased behavioral risk of HIV infection. behavioral risk of HIV infection.

Mobile VCT removed structural barriers, allowing Mobile VCT removed structural barriers, allowing individuals to confront psychological barriers.individuals to confront psychological barriers.

AcknowledgementsAcknowledgements Office of AIDS Research (OAR) and National Institute of Office of AIDS Research (OAR) and National Institute of

Mental Health (NIMH)Mental Health (NIMH) Zimbabwe Investigators: Janell Routh,Zimbabwe Investigators: Janell Routh, Katherine Fritz, Katherine Fritz,

Tinofa Mutevedzi, Taurai Vaki and Owen MapfumoTinofa Mutevedzi, Taurai Vaki and Owen Mapfumo MVCT Team and support staff at UZ-UCSF Research MVCT Team and support staff at UZ-UCSF Research

Collaborative in ZimbabweCollaborative in Zimbabwe

Epworth Community Advisory Board and Epworth Epworth Community Advisory Board and Epworth Local BoardLocal Board

UCSF AIDS Research Institute Innovative Grant UCSF AIDS Research Institute Innovative Grant ProgramProgram

UCSF Investigators: Agnes Fiamma, Edwin Charlebois, UCSF Investigators: Agnes Fiamma, Edwin Charlebois, Marisa McLaughlin, & Richard VezinaMarisa McLaughlin, & Richard Vezina

Project AcceptProject Accept

Phase III randomized controlled trial to determine Phase III randomized controlled trial to determine the efficacy of a community-level behavioral the efficacy of a community-level behavioral intervention in reducing HIV seroincidence. intervention in reducing HIV seroincidence.

Randomizing 46 CommunitiesRandomizing 46 Communities 8 in rural Zimbabwe8 in rural Zimbabwe

8 in rural Tanzania8 in rural Tanzania

8 in Soweto, South Africa8 in Soweto, South Africa

8 in Vulindlela, KwaZulu Natal, South Africa8 in Vulindlela, KwaZulu Natal, South Africa

14 in Northern Thailand14 in Northern Thailand

Mashonaland East ProvinceMashonaland East Province

Gertrude Khumalo-Sakutukwa

Email: gkhumalo-sakutukwa@psg.ucsf.edu

Tel: 415-597-9149

Gertrude Khumalo-Sakutukwa

Email: gkhumalo-sakutukwa@psg.ucsf.edu

Tel: 415-597-9149