Acceptability of integration of cervical cancer screening into routine HIV care, associated factors and perceptions among HIV-infected women: a mixed methods study at Mbarara Regional Referral Hospital, Uganda.

BACKGROUND: Integrating cervical cancer screening into routine Human Immunodeficiency Virus (HIV) care has been endorsed as an effective strategy for increasing uptake of cervical cancer screening, facilitating early detection and treatment of pre-cancerous lesions among HIV-infected women. In Uganda, this strategy has not been implemented yet in most HIV clinics. Assessing acceptability of this intervention among HIV-infected women is of great relevance to inform implementation. We assessed acceptability of integration of cervical cancer screening into routine HIV care, associated factors and perceptions among HIV-infected women enrolled in the HIV clinic at Mbarara Regional Referral Hospital. METHODOLOGY: A mixed methods study utilizing explanatory sequential approach was conducted among 327 eligible HIV-infected women. Acceptability of integration of cervical cancer screening into routine HIV care was measured based on Theoretical Framework of Acceptability. Quantitative data was collected using a pre-tested questionnaire. We conducted focus group discussions to explore perceptions regarding the intervention among purposively selected HIV-infected women. Modified Poisson regression with robust variance analysis was utilized to determine factors associated with acceptability of the intervention. Statistical significance was determined at p-value <0.05. Thematic analysis utilizing inductive coding was applied to analyse qualitative data. RESULTS: The majority of HIV-infected women (64.5%) accepted integration of cervical cancer screening into routine HIV care. Religion, perceived risk of developing cervical cancer and ever screened for cervical cancer were statistically significantly associated with acceptability of integration of cervical cancer screening into routine HIV care. Perceived benefits of the proposed intervention were: convenience to seek for cervical cancer screening, motivation to undergo cervical cancer screening, improved archiving of cervical cancer screening results, confidentiality of HIV patient information, and preference to interact with HIV clinic health workers. Shame to expose their privacy to HIV clinic health workers and increased waiting time were the only perceived challenges of the integrated strategy. CONCLUSION: Study findings highlight the need to take advantage of this acceptability to prioritize implementation of integration of cervical cancer screening into routine HIV care. HIV-infected women should be reassured of confidentiality and reduced waiting time to increase uptake of integrated cervical cancer screening and HIV services among HIV-infected women along the continuum of HIV care and treatment services.

Air quality and attributable mortality among city dwellers in Kampala, Uganda: results from 4 years of continuous PM2.5 concentration monitoring using BAM 1022 reference instrument.

BACKGROUND: Air pollution is a known risk factor for non-communicable diseases that causes substantial premature death globally. Rapid urban growth, burning of biomass and solid waste, unpaved sections of the road network, rising numbers of vehicles, some with highly polluting engines, contribute to the poor air quality in Kampala. OBJECTIVE: To provide evidence-based estimates of air pollution attributable mortality in Kampala city, with focus on ambient fine particulate matter (PM2.5). METHODS: We utilized a time series design and prospectively collected data on daily ambient PM2.5 concentration levels in micrograms per cubic meter (µg/m3) using a Beta Attenuation Monitor (BAM-1022) in Kampala city, Uganda. We combined the PM2.5 data with all-cause mortality data obtained from the Uganda Bureau of Statistics and the Ministry of Health in Kampala. We calculated attributable risk estimates for mortality using the WHO AirQ+ tools. RESULTS: Overall, the annual average concentration for PM2.5 for the period of 4 years, 2018-2021, was 39 µg/m3. There was seasonal variation, with the rainy season months (March-June and October-December) having lower values. PM2.5 concentrations tend to be highest in the morning (09.00 h) and in the evening (21.00 h.) likely due to increased vehicular emissions as well as the influence of weather patterns (atmospheric temperature, relative humidity and wind). Saturday has the most pollution (daily average over 4 years of 41.2 µg/m3). Regarding attributable risk, we found that of all the deaths in Kampala, 2777 (19.3%), 2136 (17.9%), 1281 (17.9%) and 1063 (19.8%) were attributable to long-term exposure to air pollution (i.e., exposure to PM2.5 concentrations above the WHO annual guideline of 5 µg/m3) from 2018 to 2021, respectively. For the 4 years and considering the WHO annual guideline as the reference, there were 7257 air pollution-related deaths in Kampala city. IMPACT: Our study is the first to estimate air pollution attributable deaths in Kampala city considering the target as the WHO annual guideline value for PM2.5 of 5 µg/m3. Our monitoring data show that fine particulate matter air pollution in Kampala is above the WHO Air Quality Guideline value, likely resulting in substantial adverse health effects and premature death. While further monitoring is necessary, there is a clear need for control measures to improve air quality in Kampala city.

Antenatal syphilis screening using point-of-care testing in Sub-Saharan African countries: a cost-effectiveness analysis.

BACKGROUND: Untreated syphilis in pregnancy is associated with adverse clinical outcomes for the infant. Most syphilis infections occur in sub-Saharan Africa (SSA), where coverage of antenatal screening for syphilis is inadequate. Recently introduced point-of-care syphilis tests have high accuracy and demonstrate potential to increase coverage of antenatal screening. However, country-specific cost-effectiveness data for these tests are limited. The objective of this analysis was to evaluate the cost-effectiveness and budget impact of antenatal syphilis screening for 43 countries in SSA and estimate the impact of universal screening on stillbirths, neonatal deaths, congenital syphilis, and disability-adjusted life years (DALYs) averted. METHODS AND FINDINGS: The decision analytic model reflected the perspective of the national health care system and was based on the sensitivity (86%) and specificity (99%) reported for the immunochromatographic strip (ICS) test. Clinical outcomes of infants born to syphilis-infected mothers on the end points of stillbirth, neonatal death, and congenital syphilis were obtained from published sources. Treatment was assumed to consist of three injections of benzathine penicillin. Country-specific inputs included the antenatal prevalence of syphilis, annual number of live births, proportion of women with at least one antenatal care visit, per capita gross national income, and estimated hourly nurse wages. In all 43 sub-Saharan African countries analyzed, syphilis screening is highly cost-effective, with an average cost/DALY averted of US$11 (range: US$2-US$48). Screening remains highly cost-effective even if the average prevalence falls from the current rate of 3.1% (range: 0.6%-14.0%) to 0.038% (range: 0.002%-0.113%). Universal antenatal screening of pregnant women in clinics may reduce the annual number of stillbirths by up to 64,000, neonatal deaths by up to 25,000, and annual incidence of congenital syphilis by up to 32,000, and avert up to 2.6 million DALYs at an estimated annual direct medical cost of US$20.8 million. CONCLUSIONS: Use of ICS tests for antenatal syphilis screening is highly cost-effective in SSA. Substantial reduction in DALYs can be achieved at a relatively modest budget impact. In SSA, antenatal programs should expand access to syphilis screening using the ICS test. Please see later in the article for the Editors' Summary.

Effectiveness of Clinic-Based Patient-Led Human Papillomavirus DNA Self-Sampling among HIV-Infected Women in Uganda.

In Uganda, the uptake of cervical cancer (CC) screening services is low, at 46.7%, among HIV-infected women, and only 9% of these women adhere to annual CC screening. Some studies have evaluated the possibility of community or home-based human papillomavirus (HPV) self-collected vaginal swabs, but not clinic-based HPV self-collected vaginal swabs. Therefore, we propose a study to determine the efficacy of clinic-based versus home-based HPV DNA self-sampling among HIV-infected women attending a rural HIV clinic in Uganda. We believe that a randomized, single-blinded trial would achieve this objective, and so we have chosen it to guide the study. Including a total of 382 participants from a rural HIV clinic, randomized into a ratio of 1:1 for clinic- and home-based HPV self-sampling, would allow us to appropriately ascertain the difference in the uptake of HPV self-sampling between the two arms. The Integrated Biorepository of H3 Africa Uganda Laboratory would be used as a reference laboratory for the HPV DNA extraction, typing, and sequencing. At baseline, modified Poisson regression models would be used to measure factors associated with the prevalence of HPV and uptake in both arms at baseline. Visual inspection under acetic acid (VIA), as a gold-standard test for CC to grade for CIN, would be performed at 0 and 6 months among a random sample of 75 women with a self-collected HPV sample. The difference in uptake could be determined using the intention-to-treat analysis. The difference in the groups by each variable would be summarized as the standardized mean difference (i.e., the mean difference divided by the pooled standard deviation). The predictors of the time for which participants would continue with HPV self-sampling in both arms, recovery, and Cox proportional hazards regression would be used. At the bivariate level, the associations between each independent variable and time, with the time of continuing HPV self-sampling, would be computed. Crude hazard ratios and their 95% confidence interval would be used in the presentation of the results, with p-values < 0.05 considered significant at the bivariate level. Incremental cost-effectiveness analysis (CEA) using a Markov model would be used to determine the cost of clinic-based HPV self-sampling. We believe that screening approaches to disease stratification could provide an insight into the merits and limitations of current approaches to the diagnosis of cervical cancer, and how these could eventually be implemented into HIV clinics in Uganda and other developing African countries. It is anticipated that the findings would guide the development of step-by-step guidelines for the HPV self-sampling approach.

Facilitators and Barriers to HPV Self-Sampling as a Cervical Cancer Screening Option among Women Living with HIV in Rural Uganda.

Background: There is a paucity of studies exploring women living with HIV's (WLWH) experiences relating to human papillomavirus (HPV) self-sampling as cervical cancer (CC) screening approach, either at the clinic or at the home setting, using qualitative methods. Our study explored facilitators and barriers to HPV self-sampling as a CC screening approach among human immunodeficiency virus (HIV)-infected women, as supported by the new WHO guidelines of using the HPV test as a screening modality. Methods: The study was guided by the health promotion model (HPM), which helps individuals achieve higher levels of well-being. The phenomenology design was used to explore the deeper facilitators and barriers of women regarding self-sampling, either at home or in clinical settings, at Luweero District Hospital, Uganda. The in-depth interview (IDI) guide was translated from English to Luganda. Qualitative data analysis was guided by content analysis techniques. The transcripts were coded in NVivo 20.7.0. The coded text was used to generate categories of analytically meaningful data that guided the formation of themes, the interpretation of results, and the final write-up. Results: WLWH were motivated to screen for HPV using the clinic-based approach because of perceived early diagnosis and treatment, visualization of the cervix, and free service, while reduced distance, privacy and the smooth sample collection kit were motivators for the home-based approach. A barrier that cut across the two HPV self-sampling approaches was a lack of knowledge about HPV. The barriers to clinic-based HPV self-sampling screening included lack of privacy, perceived painful procedures for visual inception under acetic acid (VIA), and fear of finding the disease. Stigma and discrimination were reported as the major barriers to the home-based HPV self-sampling approach. The major reasons why some WLWH refused to screen were fear of finding the disease, stress, and financial disruptions related to being diagnosed with CC disease. Conclusions: Therefore, early diagnosis for HPV and CC enhances clinic-based HPV self-sampling, while privacy enhances the home-based HPV self-sampling approach. However, fear of finding a disease and the lack of knowledge of HPV and CC hinders HPV self-sampling. Finally, designing pre- and post-testing counselling programs in HIV care is likely to increase the demand for HPV self-sampling.

Water, Sanitation, and Hygiene Challenges in Informal Settlements in Kampala, Uganda: A Qualitative Study.

Diarrhea causes 1.6 million deaths annually, including 525,000 children. Further, chronic diarrhea puts children at risk for mineral deficiencies, malnutrition, and stunting which, in turn, can result in cognitive deficits, poor performance in school, and decreased disease immunity in adulthood. Most diarrhea is caused by water contaminated by fecal matter. Interventions to improve clean water and sanitation can save lives; however, challenges persist in informal settlements. In this study, we explored the views of residents of informal settlements regarding water and sanitation in their communities. Focus group interviews were conducted with residents of 6 informal settlements in Kampala, Uganda (n = 165 people), and 6 key informant interviews were conducted with governmental and nongovernmental organizations that work to improve informal settlements or provide services to them. The results from this study demonstrate that, although these informal settlements had many infrastructure "upgrades" such as latrines and toilets, water taps, wells, and garbage collection and drainage systems, the water, sanitation, and hygiene (WASH) system and its components largely failed due to point-of-use charges of water taps and toilets and the difficulty of emptying cesspits. Our results suggest that WASH must be considered a system and that multiple upgrading efforts are needed for WASH systems to work, including road construction and better oversight of fecal sludge disposal.

Implementing hearing screening among children aged 0-59 months at established immunization clinics in Uganda: A multi-center study.

OBJECTIVE: The prevalence of childhood hearing loss (HL) is high in low and middle income countries (LMICs), with many of the affected children facing communication delays and poor opportunities for education. Despite the increased advocacy for childhood hearing screening globally, Uganda has no established childhood hearing screening programs. This study set out to introduce hearing screening services by non-specialist health workers at routine immunization clinics among children aged 0-59 months and describe the prevalence and factors associated with failed hearing screening (HS) in these children. METHODS: A cross-sectional multi-center study was conducted at immunization clinics at three regional referral hospitals (RRHs). A semi structured questionnaire was used to capture data on socio-demographic, clinical factors and the two stage Transient Evoked Oto-acoustic emissions (TEOAEs) screening performed on children aged 0-59 months. A child that failed two stage screening was considered to have failed HS. Logistic regression was used to calculate odds ratios (OR) for factors associated with failed HS. RESULTS: 1217 children were recruited at three RRHs, with a median age of 2 months (range: 0 to 59), half were male 52% (n = 633). Overall 45 children failed two staged TEOAE screening giving a prevalence of failed HS of 3.7%, of these 27 (2.2%) and 18 (1.5%) failed unilaterally and bilaterally respectively. Children of rural residence (aOR = 2.18, p = 0.027), of low birth weight (aOR = 0.42, p = 0.045), with relatives having hearing loss (aOR = 4.64, p= <0.001), who were admitted in hospital after birth (aOR = 3.72, p = 0.012) and a history of a childhood suppurative otitis media (aOR = 9.53, p = 0.015) all had increased odds of failed HS. CONCLUSIONS: The prevalence of failed screening is high. Implementation of childhood hearing screening by non-specialist health workers at immunization clinics using TEOAEs is possible and may be a necessary initial step in starting countrywide hearing screening in Uganda.

The preference of women living with HIV for the HPV self-sampling of urine at a rural HIV clinic in Uganda.

Background: Women living with HIV have a double risk of acquiring cervical cancer (CC) due to repeated human papilloma virus (HPV) infections resulting from reduced immunity, with CC screening being low at 46.7%. Objectives: To determine the factors associated with the preference for HPV self-sampling using urine as well as establish its feasibility among women living with HIV attending a rural HIV clinic in Uganda. Method: A cross-sectional study design using quantitative data collection methods was used at the HIV clinic, Luweero District Hospital, among 426 women aged between 30 and 65 years. Data were analysed using descriptive statistics and modified Poisson regression. Urine samples were analysed using a Liferiver high-risk HPV genotyping real-time polymerase chain reaction (PCR) kit to determine the prevalence of the 15 HPV subtypes. Cervical intraepithelial neoplasia 2 (CIN2) was determined by visual inspection under acetic acid (VIA) using the nurse-led approach. Results: Most women (296/426, 70%) preferred nurse-led screening. Preference for HPV self-sampling using urine was associated with older age (46-65 years) (adjusted prevalence risk ratios [aPRR] 1.59; 95% confidence interval [CI]: 1.13-2.24), history of sexually transmitted infections (aPRR 0.74: 95% CI: 0.55-0.98) and acquisition of CC information from the television (aPRR 1.48: 95% CI: 1.09-2.02). Approximately 97% (68/70) of women living with HIV tested HPV positive with one or more subtypes. The most prevalent subtype of HPV was HPV 58 (87.1%). Only one woman tested positive with VIA. Conclusion: Nurse-led CC screening is preferred among women living with HIV, and HPV self-sampling using urine is feasible at the HIV clinic. Therefore, educational programmes to reassure the masses about urine HPV self-sampling need to be designed. Contribution: This study's findings provide early insights into the merits and demerits of the current HPV sample collection approaches. Hence, HPV testing should be tailored to routine HIV care in rural communities.

Sexual-risk behaviours and HIV and syphilis prevalence among in- and out-of-school adolescent girls and young women in Uganda: A cross-sectional study.

BACKGROUND: Adolescent girls and young women (AGYW) are at increased risk of sexually transmitted infections (STIs). We assessed sexual-risk behaviours and HIV and syphilis prevalence among AGYW in Uganda to inform the design of target-specific risk-reduction interventions. METHODS: This analysis utilizes data from 8,236 AGYW aged 10-24 years, collected in 20 districts, between July and August 2018. AGYW engaged in sexual-risk behaviour if they: a) reported a history of STIs; or b) had their sexual debut before age 15; or c) engaged in sex with 2+ partners in the past 12 months; or c) did not use or used condoms inconsistently with their most recent partners. We diagnosed HIV using DetermineTM HIV-1/2, Stat-PakTM HIV-1/2 and SD Bioline. We used SD Bioline Syphilis test kits to diagnose syphilis and Treponema Pallidum Hemagglutination Assay for confirmatory syphilis testing. Comparison of proportions was done using Chi-square (χ2) tests. Data were analysed using STATA (version 14.1). RESULTS: Of 4,488 AGYW (54.5%) that had ever had sex, 12.9% (n = 581) had their sexual debut before age 15; 19.1% (n = 858) reported a history of STIs. Of those that had ever had sex, 79.6% (n = 3,573) had sex in the 12 months preceding the survey; 75.6% (n = 2,707) with one (1) and 24.2% (n = 866) with 2+ partners. Condom use with the most recent sexual partner was low, with only 20.4% (n = 728) reporting consistent condom use while 79.6% (n = 2,842) reported inconsistent or no condom use. In-school AGYW were significantly less likely to have ever had sex (35.6% vs. 73.6%, P<0.001), to have had sexual debut before age 15 (7.7% vs. 15.5%, P<0.001) or to engage in sex with 2+ partners (5.3% vs. 15.8%, P<0.001). Consistent condom use was significantly higher among in-school than out-of-school AGYW (40.1% vs. 12.7%, P<0.001). Overall, 1.7% (n = 143) had HIV while 1.3% (n = 104) had syphilis. HIV and syphilis prevalence was higher among out-of-school than in-school AGYW (HIV: 2.6% vs. 0.9%; syphilis: 2.1% vs. 0.5%, respectively). CONCLUSION: In-school AGYW engaged in more protective sexual behaviors and had less HIV and syphilis than their out-of-school counterparts. These findings suggest a need for target-specific risk-reduction interventions stratified by schooling status.

Utilization of safe male circumcision among adult men in a fishing community in rural Uganda.

BACKGROUND: In Uganda, most-at-riskpopulations(MARPs) such as fishing communities remain vulnerable to preventable HIV acquisition. Safe Male Circumcision (SMC) has been incorporated into Uganda's HIV prevention strategies. This study aimed at determining SMC utilization and associated factors among adult men in a rural fishing community in Uganda. METHODS: A cross-sectional study was conducted in a rural fishing village in central Uganda. Stratified random sampling of 369 fishermen aged 18-54 yearswas used according to their occupational category; fish monger, boat crew and general merchandise. The dependent variable wasutilization of SMC.A forward fitting multivariable logistic regression model was fitted with variables significant at p≤0.05 controlling for confounding and effect modification. RESULTS: Respondents'mean(SD) age was 30.0(9.3) years. Only8.4%hadSMC and among non-circumcised men, 84.9% had adequate knowledge of SMC benefits while 79.3% did not know were SMC services were offered. Peer support(AOR0.17;95%-CI0.05-0.60) and perceived procedural safety (AOR6.8;95%CI2.16-21.17) were independently associated with SMC utilization. CONCLUSION: In this rural fishing community, SMC utilization was low. These findings underscore the need to inform HIV preventionstrategies inthecontextof peer support and perceptionsheld by rural dwelling men.

Continuation of subcutaneous or intramuscular injectable contraception when administered by facility-based and community health workers: findings from a prospective cohort study in Burkina Faso and Uganda.

OBJECTIVE: The aim of this study was to examine continuation of subcutaneous and intramuscular depot medroxyprogesterone acetate (DMPA-SC and DMPA-IM) when administered by facility-based health workers in Burkina Faso and Village Health Teams (VHTs) in Uganda. STUDY DESIGN: Participants were family planning clients of health centers (Burkina Faso) or VHTs (Uganda) who had decided to initiate injectable use. Women selected DMPA-SC or DMPA-IM and study staff followed them for up to four injections (providing 12 months of pregnancy protection) to determine contraceptive continuation. Study staff interviewed women at their first injection (baseline), second injection, fourth injection and if they discontinued either product. RESULTS: Twelve-month continuation in Burkina Faso was 50% for DMPA-SC and 47.4% for DMPA-IM (p=.41, N=990, 492 DMPA-SC and 498 DMPA-IM). Twelve-month continuation in Uganda was 77.8% for DMPA-SC and 77.4% for DMPA-IM (p=.85, N=1224, 609 DMPA-SC and 615 DMPA-IM). Reasons for discontinuation of DMPA across groups in Burkina Faso included side effects (90/492, 18.3%), being late for injection (68/492, 13.8%) and refusal of spouse (51/492, 10.4%). Reasons for discontinuation in Uganda included being late for injection (65/229, 28.4%), received from non-VHT (50/229, 21.8%) and side effects (34/229, 14.8%). Increased age (adjusted hazard ratio=0.98, p=.01) and partner acceptance of family planning (adjusted hazard ratio=0.48, p<.001) had protective effects against discontinuation in Burkina Faso; we did not find statistically significant variables in Uganda. CONCLUSIONS: There is no difference in 12-month continuation (through four injections) between DMPA-SC and DMPA-IM whether from facility-based health workers in Burkina Faso or VHTs in Uganda. Continuation was higher through community-based distribution in Uganda than health facilities in Burkina Faso. IMPLICATIONS: The subcutaneous formulation of depot medroxyprogesterone acetate (DMPA-SC) is increasingly available in Family Planning 2020 countries. Use of DMPA-SC does not appear to change continuation relative to traditional intramuscular DMPA. Growing evidence of DMPA-SC's suitability for community-based distribution and self-injection may yield indirect benefits for contraceptive continuation and help reach new users.

Acceptability of cervical cancer screening using visual inspection among women attending a childhood immunization clinic in Uganda.

OBJECTIVE: To evaluate the acceptability and performance of cervical cancer (CC) screening using visual inspection with acetic acid (VIA) integrated into a rural immunization clinic in Uganda. METHODS/MATERIALS: We conducted a cross-sectional pilot study in rural Uganda. We explored associations between women's characteristics and acceptance of VIA testing. We collected samples for Papanicolaou (Pap) smear testing in a random subset of women and used results from this test as a comparator for assessing VIA performance. RESULTS: We enrolled 625 women of whom 571 (91.4%) accepted and 54 (8.6%) refused CC screening. In the univariate model, age (Odds Ratio (OR)=1.10; p-value<0.001) and employment status (OR 2.00; p-value=0.019) were significantly associated with acceptance of VIA screening. In the multivariate model, no characteristic was independently associated with acceptance of VIA screening after adjusting for other factors. Compared to reference Pap smear, CC screening with VIA had a sensitivity of 50% and a specificity of 97.7%. CONCLUSIONS: CC screening with VIA is highly acceptable in the setting of rural immunization clinics in Uganda. Studies to assess which screening method would be the most effective and cost-effective are needed before stakeholders can consider adopting screening programs at scale.

Determinants of utilization of a no-cost HIV transition clinic: a cross-sectional study of young adults living with HIV/AIDS.

There is minimal research that has been conducted among young adults to understand the determinants of the utilization of human immunodeficiency virus (HIV) health services in this population. The purpose of this study was to explore the levels and determinants of HIV transition clinic (HTC) services utilization by young adults living with HIV/acquired immunodeficiency syndrome (YALHA). The study used a cross-sectional design and quantitative methods to collect data from a sample of 379 YALHA between the ages of 15-24 years who were registered clients of an HTC in Uganda. During data analysis, utilization was categorized into two levels: regular (kept all appointment visits) and irregular (missed one or more appointment visits) utilization. Univariable, bivariable, and multivariable logistic regression analyses were used to examine the determinants associated with HTC utilization. The HTC services that were most utilized by the YALHA were those based at the clinic and provided by professional health care providers and these were: clinical examination (96%); laboratory services (87.1%); and counseling (69.7%). The services that were least utilized were home visiting (5.8%) and peer support services (19.8%). Of the 379 YALHA, only 32.4% regularly utilized the HTC. Multivariable analysis showed that the main determinants of HTC utilization were CD4 count category of ≥251/µL (adjusted odds ratio [AOR] =0.58, 95% confidence interval [CI] =0.36-0.95); not being on antiretroviral therapy (AOR =0.27, 95% CI =0.15-0.47); and not receiving counseling services (AOR =0.47, 95% CI =0.27-0.83). Regular utilization of the HTC by YALHA was low and utilization seems to be influenced by HIV infection stage and HIV counseling services, but not sociodemographic factors or community factors.