Examining the association between HIV prevalence and socioeconomic factors among young people in Zambia: Do neighbourhood contextual effects play a role?

BACKGROUND: The study examined the association between HIV infection and individual and neighbourhood-level socioeconomic factors in Zambia. METHODS: We used multilevel mixed effects logistic regression to examine the association of individual and neighbourhood level variables on HIV prevalence based on data from the 2013-14 and 2018 Zambia Demographic and Health Surveys, population-based cross-sectional surveys. The analysis was restricted to young people (15-24 years) with HIV serostatus results (n = 11,751 and n = 10,154). HIV serostatus was the outcome variable and socioeconomic status was measured by wealth, education and employment. RESULTS: Overall, at individual level, education was associated with reduced odds of HIV infection among young women and men. Conversely, relative wealth was generally associated with increased odds of infection for both young women and men. Young, employed men were at reduced odds of HIV infection than the unemployed. Living in neighbourhoods with higher average level of education was associated with higher odds of HIV infection. In 2013-14, 13% and 11% of the variation in HIV infection among young men and women was attributed to neighbourhoods, while 20% and 11% variation was attributed to neighbourhoods in 2018. Inclusion of individual and neighbourhood variables in the full regression model accounted for 65.7% and 59.5% of explained variance in 2013-14 and 64.6% and 44.3% in 2018, for women and men, respectively. This reduced unexplained variance by an average of 56% in 2013-14 and 29% in 2018. CONCLUSION: We found that HIV infection among young people in Zambia is more strongly associated with individual-level socioeconomic factors compared to neighbourhood factors. Individual-level education remains an important socioeconomic factor associated with reduced odds of HIV infection. This suggests that the HIV response in Zambia should still focus on individual level prevention strategies.

The value of general health perception in health equity research: A community-based cohort study of long-term mortality risk (Finnmark cohort study 1987-2017).

BACKGROUND: General health perception as measured by self-rated health (SRH) is an individual's synthesis of personal overall health and has value in its own right. In addition, this subjective perspective has a unique predictive power of subsequent mortality and adds valuable information not captured by objective measures. We studied the relationship between SRH and subsequent mortality to demonstrate how simple self-ratings can enhance our understanding of health inequities. METHODS: Data from a population-based survey conducted in Finnmark 1987/1988 were linked to the Norwegian Cause of Death Registry for information on all deaths by the end of 2017. We used Cox proportional hazard regression modelling to estimate the relative effects of all-cause mortality separately for sex and age (30-49 and 50-62 years) with stepwise adjustment for socio-demographics and various other health status and behavioural measures. RESULTS: The age-adjusted power of mortality prediction of SRH was strong (most pronounced in the youngest age-group) but markedly attenuated by other factors. Education inequality in mortality was most substantial in the youngest age-group, which might partly be due to a combination of selective mortality and historical changes in health inequality. In comparison, educational inequality in SRH was clearly pronounced regardless of age. Work disability pension appeared as the common key factor affecting the mortality prediction of SRH and educational inequity for both subsequent mortality and SRH. CONCLUSION: SRH adds unique information to our understanding of health inequities. The consistency in shared predictors of educational inequity concerning both mortality and SRH underscores the correspondence of these measures. In addition to predicting the fatal effects of social selection mechanisms, SRH adds non-fatal effects and seems less prone to selective mortality. The results are relevant to approaches in health equity research and have important policy implications.

Contrasting HIV prevalence trends among young women and men in Zambia in the past 12 years: data from demographic and health surveys 2002-2014.

BACKGROUND: The HIV epidemic remains a concern on the global health agenda, despite progress made in reducing incidence. Investigation of trends among young people is important for monitoring HIV incidence and informing programming. The study examined geographical and sub-population differences in HIV prevalence trends among young people aged 15-24 years in Zambia. METHODS: This study analysed data from Zambia Demographic and Health Surveys (ZDHSs) that were conducted in 2001-2, 2007, and 2013-14. A two-stage cluster stratified sampling procedure was used to select samples of 8050, 7969, and 18,052 for the three surveys, respectively. Young people (15-24 years) with known HIV status were selected for analysis. The outcome variable was HIV status. Log binomial regression analysis of generalised linear models was used to test for trends. RESULTS: Overall HIV prevalence declined over the period 2001-2 to 2013-14 among women and men aged 15-49 years (17.8 and 12.9% to 15.1 and 11.3%, respectively). There was, however, an increase in HIV prevalence among urban young men over this period, from 3.7% in 2001-2 to 7.3% in 2013-14 (aRR 2.17, 95% CI 0.99-4.75), and, in rural areas, from 2.6 to 3.6% (aRR 1.46, 95% CI 0.78-2.75). In contrast, HIV prevalence among women declined over the same period of time. In urban areas, HIV prevalence among women declined from 15.2 to 10.7% (aRR 0.66, 95% CI 0.53-0.93), while in rural areas it declined from 8.2 to 4.8% (aRR 0.41, 95% CI 0.59-0.85). In addition, there was a narrowing gender gap in terms of HIV infection, as the prevalence ratio of females to males declined from 4.2 and 3.1 to 1.5 and 1.3, in urban and rural areas, respectively. CONCLUSIONS: The increase in HIV prevalence among urban young men over the past 12 years, contrasting declining trends among young women in both urban and rural populations, suggests differential effects of prevention efforts. Furthermore, findings that Zambia's overall national HIV prevalence decline masks some striking sex and rural/urban differentials, indicate the need for reconsidering the prevention efforts for young urban men.

Effectiveness of a girls' empowerment programme on early childbearing, marriage and school dropout among adolescent girls in rural Zambia: study protocol for a cluster randomized trial.

BACKGROUND: Adolescent pregnancies pose a risk to the young mothers and their babies. In Zambia, 35% of young girls in rural areas have given birth by the age of 18 years. Pregnancy rates are particularly high among out-of-school girls. Poverty, low enrolment in secondary school, myths and community norms all contribute to early childbearing. This protocol describes a trial aiming to measure the effect on early childbearing rates in a rural Zambian context of (1) economic support to girls and their families, and (2) combining economic support with a community intervention to enhance knowledge about sexual and reproductive health and supportive community norms. METHODS/DESIGN: This cluster randomized controlled trial (CRCT) will have three arms. The clusters are rural schools with surrounding communities. Approximately 4900 girls in grade 7 in 2016 will be recruited from 157 schools in 12 districts. In one intervention arm, participating girls and their guardians will be offered cash transfers and payment of school fees. In the second intervention arm, there will be both economic support and a community intervention. The interventions will be implemented for approximately 2 years. The final survey will be 4.5 years after recruitment. The primary outcomes will be "incidence of births within 8 months of the end of the intervention period", "incidence of births before girls' 18th birthday" and "proportion of girls who sit for the grade 9 exam". Final survey interviewers will be unaware of the intervention status of respondents. Analysis will be by intention-to-treat and adjusted for cluster design and confounders. Qualitative process evaluation will be conducted. DISCUSSION: This is the first CRCT to measure the effect of combining economic support with a community intervention to prevent adolescent childbearing in a low- or middle-income country. We have designed a programme that will be sustainable and feasible to scale up. The findings will be relevant for programmes for adolescent reproductive health in Zambia and similar contexts. TRIAL REGISTRATION: ISRCTN registry: ISRCTN12727868 , (4 March 2016).

Sex Differences in HIV Prevalence Persist over Time: Evidence from 18 Countries in Sub-Saharan Africa.

OBJECTIVE: The aim of this study was to examine changes over time in the female: male HIV prevalence ratio in 18 countries in Sub-Saharan Africa, overall and when stratified by area of residence, educational attainment and marital status. METHODOLOGY: We used data from the Demographic and Health Surveys, which are nationally representative household surveys. By using data from 18 countries with at least two survey rounds with HIV testing, and dividing the countries into three regions (Western/Central, Eastern and Southern) we were able to examine cross-country and regional changes in the female: male HIV prevalence ratio over time. Logistic regression was used to estimate female: male HIV prevalence ratios in urban versus rural areas and for different categories of education and marital status. To assess changes over time, we compared the confidence intervals of the prevalence ratios. RESULTS: The female: male HIV prevalence ratio was above one in all countries in at least one survey round for both ages 15-24 years and 25-49 years. In 13 out of 18 countries the prevalence ratio was higher for the younger age group compared to the age group 25-49 years (3 significant) and this difference in prevalence ratios between the age groups did not change over time. Overall, there was a higher frequency of increasing than decreasing prevalence ratios. The gender disparity was greater among those who were married/living together than among the never-married, and over time, the ratio was more stable among the married/living together. The study found no clear differential changes by education. CONCLUSION: Women continue to carry the greater burden of HIV in Sub-Saharan Africa and there is no clear pattern of change in the gap between men and women as the direction and magnitude of change in the prevalence ratios varied greatly.

Rural-Urban Inequity in Unmet Obstetric Needs and Functionality of Emergency Obstetric Care Services in a Zambian District.

BACKGROUND: Zambia has a high maternal mortality ratio, 398/100,000 live births. Few pregnant women access emergency obstetric care services to handle complications at childbirth. We aimed to assess the deficit in life-saving obstetric services in the rural and urban areas of Kapiri Mposhi district. METHOD: A cross-sectional survey was conducted in 2011 as part of the 'Response to Accountable priority setting for Trust in health systems' (REACT) project. Data on all childbirths that occurred in emergency obstetric care facilities in 2010 were obtained retrospectively. Sources of information included registers from maternity ward admission, delivery and operation theatre, and case records. Data included age, parity, mode of delivery, obstetric complications, and outcome of mother and the newborn. An approach using estimated major obstetric interventions expected but not done in health facilities was used to assess deficit of life-saving interventions in urban and rural areas. RESULTS: A total of 2114 urban and 1226 rural childbirths occurring in emergency obstetric care facilities (excluding abortions) were analysed. Facility childbirth constituted 81% of expected births in urban and 16% in rural areas. Based on the reference estimate that 1.4% of childbearing women were expected to need major obstetric intervention, unmet obstetric need was 77 of 106 women, thus 73% (95% CI 71-75%) in rural areas whereas urban areas had no deficit. Major obstetric interventions for absolute maternal indications were higher in urban 2.1% (95% CI 1.60-2.71%) than in rural areas 0.4% (95% CI 0.27-0.55%), with an urban to rural rate ratio of 5.5 (95% CI 3.55-8.76). CONCLUSIONS: Women in rural areas had deficient obstetric care. The likelihood of under-going a life-saving intervention was 5.5 times higher for women in urban than rural areas. Targeting rural women with life-saving services could substantially reduce this inequity and preventable deaths.

Accuracy in HIV Rapid Testing among Laboratory and Non-laboratory Personnel in Zambia: Observations from the National HIV Proficiency Testing System.

BACKGROUND: Despite rapid task-shifting and scale-up of HIV testing services in high HIV prevalence countries, studies evaluating accuracy remain limited. This study aimed to assess overall accuracy level and factors associated with accuracy in HIV rapid testing in Zambia. METHODS: Accuracy was investigated among rural and urban HIV testing sites participating in two annual national HIV proficiency testing (PT) exercises conducted in 2009 (n = 282 sites) and 2010 (n = 488 sites). Testers included lay counselors, nurses, laboratory personnel and others. PT panels of five dry tube specimens (DTS) were issued to testing sites by the national reference laboratory (NRL). Site accuracy level was assessed by comparison of reported results to the expected results. Non-parametric rank tests and multiple linear regression models were used to assess variation in accuracy between PT cycles and between tester groups, and to examine factors associated with accuracy respectively. RESULTS: Overall accuracy level was 93.1% (95% CI: 91.2-94.9) in 2009 and 96.9% (95% CI: 96.1-97.8) in 2010. Differences in accuracy were seen between the tester groups in 2009 with laboratory personnel being more accurate than non-laboratory personnel, while in 2010 no differences were seen. In both PT exercises, lay counselors and nurses had more difficulties interpreting results, with more occurrences of false-negative, false-positive and indeterminate results. Having received the standard HIV rapid testing training and adherence to the national HIV testing algorithm were positively associated with accuracy. CONCLUSION: The study showed an improvement in tester group and overall accuracy from the first PT exercise to the next. Average number of incorrect test results per 1000 tests performed was reduced from 69 to 31. Further improvement is needed, however, and the national HIV proficiency testing system seems to be an important tool in this regard, which should be continued and needs to be urgently strengthened.

Rural-urban differentials in pregnancy-related mortality in Zambia: estimates using data collected in a census.

BACKGROUND: The use of census data to measure maternal mortality is a recent phenomenon, implemented in settings with non-functional vital registration systems and driven by needs for trend data. The 2010 round of population and housing censuses recorded a significant increase in the number of countries collecting maternal mortality data. The objective of this study was to estimate rural-urban differentials in pregnancy-related mortality in Zambia using census data. METHODS: We used data from the Zambia 2000 and 2010 censuses. Both censuses recorded the female population by age, the number of children ever born, and live births 12 months prior to the census. The 2010 census further recorded, by age, household, and pregnancy-related deaths 12 months prior to the census. We evaluated and adjusted recorded live births using the cohort Parity Fertility ratio method, and household deaths using deaths distribution methods (General Growth Balance and Synthetic Extinct Generation). Adult female mortality and pregnancy-related mortality for rural and urban areas were estimated for the period October 2009 to October 2010. RESULTS: Data evaluation showed errors in recorded population age, age-at-death, live births, and deaths, and appropriate adjustments were made. Adjusted adult female mortality was high; an adolescent aged 15 years had a one-in-three chance of dying before her 50th birthday in rural areas and one-in-four chance in urban areas. Pregnancy-related deaths comprised 15.3 % of all deaths among reproductive-age women overall; 17.9 % in rural areas and 9.8 % in urban areas. The pregnancy-related mortality ratio for the period was 789 deaths/100,000 live births overall: 960/100,000 live births in rural areas and 470/100,000 live births in urban areas. CONCLUSIONS: Census-based estimates show very high adult female mortality and particularly high pregnancy-related mortality in both rural and urban areas of Zambia 12 months prior to the 2010 census. Future censuses should pay greater attention to strategies for improving data quality.

Task-Shifting and Quality of HIV Testing Services: Experiences from a National Reference Hospital in Zambia.

BACKGROUND: With new testing technologies, task-shifting and rapid scale-up of HIV testing services in high HIV prevalence countries, assuring quality of HIV testing is paramount. This study aimed to explore various cadres of providers' experiences in providing HIV testing services and their understanding of elements that impact on quality of service in Zambia. METHODS: Sixteen in-depth interviews and two focus group discussions were conducted with HIV testing service providers including lay counselors, nurses and laboratory personnel at purposively selected HIV testing sites at a national reference hospital in Lusaka. Qualitative content analysis was adopted for data analysis. RESULTS: Lay counselors and nurses reported confidentiality and privacy to be greatly compromised due to limited space in both in- and out-patient settings. Difficulties in upholding consent were reported in provider-initiated testing in in-patient settings. The providers identified non-adherence to testing procedures, high workload and inadequate training and supervision as key elements impacting on quality of testing. Difficulties related to testing varied by sub-groups of providers: lay counselors, in finger pricking and obtaining adequate volumes of specimen; non-laboratory providers in general, in interpreting invalid, false-negative and false-positive results. The providers had been participating in a recently established national HIV quality assurance program, i.e. proficiency testing, but rarely received site supervisory visits. CONCLUSION: Task-shifting coupled with policy shifts in service provision has seriously challenged HIV testing quality, protection of confidentiality and the process of informed consent. Ways to better protect confidentiality and informed consent need careful attention. Training, supervision and quality assurance need strengthening tailored to the needs of the different cadres of providers.

Impact of Pregnancy-Related Deaths on Female Life Expectancy in Zambia: Application of Life Table Techniques to Census Data.

INTRODUCTION: Since 2000, the world has been coalesced around efforts to reduce maternal mortality. However, few studies have estimated the significance of eliminating maternal deaths on female life expectancy. We estimated, based on census data, the potential gains in female life expectancy assuming complete elimination of pregnancy-related mortality in Zambia. METHODS: We used data on all-cause and pregnancy-related deaths of females aged 15-49 reported in the Zambia 2010 census, and evaluated, adjusted and smoothed them using existing and verified techniques. We used associated single decrement life tables, assuming complete elimination of pregnancy-related deaths to estimate the potential gains in female life expectancy at birth, at age 15, and over the ages 15-49. We compared these gains with the gains from eliminating deaths from accidents, injury, violence and suicide. RESULTS: Complete elimination of pregnancy-related deaths would extend life expectancy at birth among Zambian women by 1.35 years and life expectancy at age 15 by 1.65 years. In rural areas, this would be 1.69 years and 2.19 years, respectively, and in urban areas, 0.78 years and 0.85 years. An additional 0.72 years would be spent in the reproductive age group 15-49; 1.00 years in rural areas and 0.35 years in urban areas. Eliminating deaths from accidents, injury, suicide and violence among women aged 15-49 would cumulatively contribute 0.55 years to female life expectancy at birth. CONCLUSION: Eliminating pregnancy-related mortality would extend female life expectancy in Zambia substantially, with more gains among adolescents and females in rural areas. The application of life table techniques to census data proved very valuable, although rigorous evaluation and adjustment of reported deaths and age was necessary to attain plausible estimates. The collection of detailed high quality cause-specific mortality data in future censuses is indispensable.

'Born before arrival': user and provider perspectives on health facility childbirths in Kapiri Mposhi district, Zambia.

BACKGROUND: Maternal mortality remains high in sub-Saharan Africa. Health facility intra-partum strategies with skilled birth attendance have been shown to be most effective to address maternal mortality. In Zambia, the health policy for pregnant women is to have facility childbirth, but less than half of the women utilize the facilities for delivery. 'Born before arrival' (BBA) describes childbirth that occurs outside health facility. With the aim to increase our understanding of trust in facility birth care we explored how users and providers perceived the low utilization of health facilities during childbirth. METHODS: A qualitative study was conducted in Kapiri Mposhi, Zambia. Focus group discussions with antenatal clinic and outpatient department attendees were conducted in 2008 as part of the Response to Accountable priority setting and Trust in health systems project, (REACT). In-depth interviews conducted with women who delivered at home, their husbands, community leaders, traditional birth attendants, and midwives were added in 2011. Information was collected on perceptions and experiences of home and health facility childbirth, and reasons for not utilizing a facility at delivery. Data were analysed by inductive content analysis. RESULTS: Perspectives of users and providers were grouped under themes that included experiences related to promotion of facility childbirth, responsiveness of health care providers, and giving birth at home. Trust and quality of care were important when individuals seek facility childbirth. Safety, privacy and confidentiality encouraged facility childbirth. Poor attitudes of health providers, long distances and lack of transport to facilities, costs to buy delivery kits, and cultural ideals that local herbs speed up labour and women should exhibit endurance at childbirth discouraged facility childbirth. CONCLUSION: Trust and perceived quality of care were important and influenced health care seeking at childbirth. Interventions that include both the demand and supply sides of services with prioritizing needs of the community could substantially improve trust and utilization of facilities at childbirth, and accelerate efforts to achieve MDG5.

Factors associated with health facility childbirth in districts of Kenya, Tanzania and Zambia: a population based survey.

BACKGROUND: Maternal mortality continues to be a heavy burden in low and middle income countries where half of all deliveries take place in homes without skilled attendance. The study aimed to investigate the underlying and proximate determinants of health facility childbirth in rural and urban areas of three districts in Kenya, Tanzania and Zambia. METHODS: A population-based survey was conducted in 2007 as part of the 'REsponse to ACcountable priority setting for Trust in health systems' (REACT) project. Stratified random cluster sampling was used and the data included information on place of delivery and factors that might influence health care seeking behaviour. A total of 1800 women who had childbirth in the previous five years were analysed. The distal and proximate conceptual framework for analysing determinants of maternal mortality was modified for studying factors associated with place of delivery. Socioeconomic position was measured by employing a construct of educational attainment and wealth index. All analyses were stratified by district and urban-rural residence. RESULTS: There were substantial inter-district differences in proportion of health facility childbirth. Facility childbirth was 15, 70 and 37% in the rural areas of Malindi, Mbarali and Kapiri Mposhi respectively, and 57, 75 and 77% in the urban areas of the districts respectively. However, striking socio-economic inequities were revealed regardless of district. Furthermore, there were indications that repeated exposure to ANC services and HIV related counselling and testing were positively associated with health facility deliveries. Perceived distance was negatively associated with facility childbirth in rural areas of Malindi and urban areas of Kapiri Mposhi. CONCLUSION: Strong socio-economic inequities in the likelihood of facility childbirths were revealed in all the districts added to geographic inequities in two of the three districts. This strongly suggests an urgent need to strengthen services targeting disadvantaged and remote populations. The finding of a positive association between HIV counselling/testing and odds in favor of giving birth at a health facility suggests potential positive effects can be achieved by strengthening integrated approaches in maternal health service delivery.

The seven Cs of the high acceptability of home-based VCT: results from a mixed methods approach in Zambia.

HIV testing and counselling is a critical gateway to prevention and treatment. Yet, coverage remains insufficient, few couples are tested together and gender differences in access exist. We used an embedded mixed methods approach to investigate possible explanations for the high acceptance of home-based voluntary HIV counselling and testing (HB-VCT) in a pair-matched cluster-randomized trial in Zambia. A baseline survey included 1694 individuals in 36 clusters. Adults in 18 intervention clusters were offered HB-VCT by lay counsellors. Standard testing services were available in both trial arms. After the completion of the intervention, a follow-up survey was conducted in all trial clusters. In addition, 21 in-depth interviews and one focus group discussion were conducted with home-based VCT clients in the intervention arm. Informants favoured the convenience, confidentiality and credibility of HB-VCT. Counsellors were perceived as trustworthy owing to their closeness and conduct, and the consent process was experienced as convincing. Couple testing was selected by 70% of cohabiting couples and was experienced as beneficial by both genders. Levels of first-time testing (68% vs. 29%, p < 0.0001) and re-testing (94% vs. 74%, p < 0.0001) were higher in the intervention than in the control arm. Acceptance of HIV testing and counselling is dependent on stigma, trust and gender. The confidentiality of home-based VCT was essential for overcoming stigma-related barriers, and the selection of local counsellors was important to ensure trust in the services. The high level of couple counselling within HB-VCT may contribute to closing the gender gap in HIV testing, and has benefits for both genders and potentially for prevention of HIV transmission. The study demonstrates the feasibility of achieving high test coverage with an opt-in consent approach. The embedded qualitative component confirmed the high satisfaction with HB-VCT reported in the quantitative survey and was crucial to fully understand the intervention and its consequences.

Decline in sexual risk behaviours among young people in Zambia (2000-2009): do neighbourhood contextual effects play a role?

OBJECTIVE: This study examined trends in premarital sex, multiple partnership and condom use among young people (15-24 years) in Zambia from 2000 to 2009, and assessed the effects of individual and neighbourhood variables on these sexual behaviour indicators in 2000 and 2009. METHODOLOGY: We analysed data from the Zambia Sexual Behaviour Survey, conducted in 2000, 2003, 2005 and 2009. Multi-stage cluster sampling was used to select 385 neighbourhoods, giving a population sample of 6,500 young people. Using linear-by-linear trend test, trends in the three indicators were examined. Multilevel logistic regression was used to assess the effects of individual and neighbourhood variables on the indicators. RESULTS: Premarital sex among young people decreased significantly from 51 to 42% between 2000 and 2009. Multiple partnerships of men also decreased from 26 to 14% during the same period. The use of condoms by young people remained stable during this period. Full multilevel regression models explained 29 and 34% of the neighbourhood variance of premarital sex in 2000 and 2009. For multiple partnerships and condom use, the explained variance was 29 and 18% in 2000; whereas in 2009 it was extremely low. Urban residence and living in neighbourhood with higher average duration of residence were associated with low premarital sex and higher condom use. Living in a neighbourhood with higher average level of comprehensive knowledge of HIV was associated with less risky sexual behaviour. CONCLUSION: Declining trends in premarital sex and multiple partnerships are among the factors that might explain the decrease in HIV incidence in Zambia among young people. However, condom use among young people has remained low and stable over the years. The results also suggest that behaviour change interventions should take stock of the social context when introducing individual-level programmes because neighbourhood factors play a considerable role in influencing sexual behaviour.

Strong effects of home-based voluntary HIV counselling and testing on acceptance and equity: a cluster randomised trial in Zambia.

Home-based voluntary HIV counselling and testing (HB-VCT) has been reported to have a high uptake, but it has not been rigorously evaluated. We designed a model for HB-VCT appropriate for wider scale-up, and investigated the acceptance of home-based counselling and testing, equity in uptake and negative life events with a cluster-randomized trial. Thirty six rural clusters in southern Zambia were pair-matched based on baseline data and randomly assigned to the intervention or the control arm. Both arms had access to standard HIV testing services. Adults in the intervention clusters were offered HB-VCT by local lay counsellors. Effects were first analysed among those participating in the baseline and post-intervention surveys and then as intention-to-treat analysis. The study was registered with www.controlled-trials.com, number ISRCTN53353725. A total of 836 and 858 adults were assigned to the intervention and control clusters, respectively. In the intervention arm, counselling was accepted by 85% and 66% were tested (n = 686). Among counselled respondents who were cohabiting with the partner, 62% were counselled together with the partner. At follow-up eight months later, the proportion of adults reporting to have been tested the year prior to follow-up was 82% in the intervention arm and 52% in the control arm (Relative Risk (RR) 1.6, 95% CI 1.4-1.8), whereas the RR was 1.7 (1.4-2.0) according to the intention-to-treat analysis. At baseline the likelihood of being tested was higher for women vs. men and for more educated people. At follow-up these differences were found only in the control communities. Measured negative life events following HIV testing were similar in both groups. In conclusion, this HB-VCT model was found to be feasible, with a very high acceptance and to have important equity effects. The high couple counselling acceptance suggests that the home-based approach has a particularly high HIV prevention potential.

Effects of home-based voluntary counselling and testing on HIV-related stigma: findings from a cluster-randomized trial in Zambia.

HIV-related stigma continues to be a prominent barrier to testing, treatment and care. However, few studies have investigated changes in stigma over time and the factors contributing to these changes, and there is no evidence of the impact of HIV testing and counselling on stigma. This study was nested within a pair-matched cluster-randomized trial on the acceptance of home-based voluntary HIV counselling and testing conducted in a rural district in Zambia between 2009 and 2011, and investigated changes in stigma over time and the impact of HIV testing and counselling on stigma. Data from a baseline survey (n = 1500) and a follow-up survey (n = 1107) were used to evaluate changes in stigma. There was an overall reduction of seven per cent in stigma from baseline to follow-up. This was mainly due to a reduction in individual stigmatizing attitudes but not in perceived stigma. The reduction did not differ between the trial arms (ß = -0.22, p = 0.423). Being tested for HIV was associated with a reduction in stigma (ß = -0.57, p = 0.030), and there was a trend towards home-based Voluntary Counselling and Testing having a larger impact on stigma than other testing approaches (ß = -0.78, p = 0.080 vs. ß = -0.37, p = 0.551), possibly explained by a strong focus on counselling and the safe environment of the home. The reduction observed in both arms may give reason to be optimistic as it may have consequences for disclosure, treatment access and adherence. Yet, the change in stigma may have been affected by social desirability bias, as extensive community mobilization was carried out in both arms. The study underscores the challenges in measuring and monitoring HIV-related stigma. Adjustment for social desirability bias and inclusion of qualitative methods are recommended for further studies on the impact of HIV testing on stigma.

Persisting stigma reduces the utilisation of HIV-related care and support services in Viet Nam.

BACKGROUND: Seeking and utilisation of HIV prevention, treatment, care, and support services for people living with HIV is often hampered by HIV-related stigma. The study aimed to explore the perceptions and experiences regarding treatment, care, and support amongst people living with HIV in Viet Nam, where the HIV epidemic is concentrated among injecting drug users, sex workers, and men who have sex with men. METHODS: In-depth interviews and focus group discussions were conducted during September 2007 in 6 districts in Hai Phong with a very high HIV prevalence among injecting drug users. The information obtained was analysed and merged within topic areas. Illustrative quotes were selected. RESULTS: Stigma and discrimination against people living with HIV in the community and healthcare settings was commonly reported, and substantially hampered the seeking and the utilisation of HIV-related services. The informants related the high level of stigma to the way the national HIV preventive campaigns played on fear, by employing a "scare tactic" mainly focusing on drug users and sex workers, who were defined as "social evils" in the anti-drug and anti-prostitution policy. There was a strong exclusion effect caused by the stigma, with serious implications, such as loss of job opportunities and isolation. The support and care provided by family members was experienced as vital for the spirit and hope for the future among people living with HIV. CONCLUSIONS: A comprehensive care and support programme is needed. The very high levels of stigma experienced seem largely to have been created by an HIV preventive scare tactic closely linked to the "social evil" approach in the national policy on drug and prostitution. In order to reduce the stigma and create more effective interventions, this tactic will have to be replaced with approaches that create better legal and policy environments for drug users and sex workers.

Health status and socio-economic factors associated with health facility utilization in rural and urban areas in Zambia.

BACKGROUND: With regards to equity, the objective for health care systems is "equal access for equal needs". We examined associations of predisposing, enabling and need factors with health facility utilization in areas with high HIV prevalence and few people being aware of their HIV status. METHODS: The data is from a population-based survey among adults aged 15years or older conducted in 2003. The current study is based on a subset of this data of adults 15-49 years with a valid HIV test result. A modified Health behaviour model guided our analytical approach. We report unadjusted and adjusted odds ratios and their 95% confidence intervals from logistic regression analyses. RESULTS: Totals of 1042 males and 1547 females in urban areas, and 822 males and 1055 females in rural areas were included in the study. Overall, 53.1% of urban and 56.8% of rural respondents utilized health facilities past 12 months. In urban areas, significantly more females than males utilized health facilities (OR=1.4 (95% CI [1.1, 1.6]). Higher educational attainment (10+ years of schooling) was associated with utilization of health facilities in both urban (OR=1.7, 95% CI [1.3, 2.1]) and rural (OR=1.4, 95% CI [1.0, 2.0]) areas compared to respondents who attained up to 7 years of schooling. Respondents who self-rated their health status as very poor/ poor/fair were twice more likely to utilize health facilities compared to those who rated their health as good/excellent. Respondents who reported illnesses were about three times more likely to utilize health facilities compared to those who did not report the illnesses. In urban areas, respondents who had mental distress were 1.7 times more likely to utilize health facilities compare to those who had no mental distress. Compared to respondents who were HIV negative, respondents who were HIV positive were 1.3 times more likely to utilize health facilities. CONCLUSION: The health care needs were the factors most strongly associated with health care seeking. After accounting for need differentials, health care seeking differed modestly by urban and rural residence, was somewhat skewed towards women, and increased substantially with socioeconomic position.

Risk factors, healthcare-seeking and sexual behaviour among patients with genital ulcers in Zambia.

BACKGROUND: Genital ulcers (GU) are associated with an increased risk of HIV transmission. Understanding risk factors for genital ulcers and sexual behaviour patterns after onset of symptoms and health seeking behaviour among GU-patients can provide useful information to aid design effective prevention strategies for genital ulcers. We investigated risk factors of self-reported GUs and care-seeking in the general population, and assessed GU patients regarding past care-seeking, recent sexual behaviour and partner awareness of the disease. METHODS: We analysed national data on genital ulcers from the 2007 Zambia Demographic and Health Survey, and data from a cross-sectional survey of genital ulcer patients from primary health care facilities in Lusaka, Zambia. RESULTS: The prevalence of GU in 2007 in the general population of Lusaka was 3.6%. Important predictors for genital ulcers were age 25-29 years, being widowed/separated/divorced and having a high number of life-time sexual partners. No differences in care-seeking were observed by residence, wealth and gender, and 60% of the respondents sought care from public health facilities. Among patients with GUs in Lusaka, 14% sought care >2 weeks after symptom onset. Forty-two percent were not aware of their HIV status, 57% reported sex after onset of symptoms and only 15% reported consistent condom use. CONCLUSIONS: Low awareness of HIV status despite high probability of being infected and low condom use after onset of genital ulcer symptoms leads to a high potential for transmission to sexual partners. This, combined with the fact that many patients with GUs delayed seeking care, shows a need for awareness campaigns about GUs and the importance of abstinence or use of condoms when experiencing such symptoms.

Factors affecting voluntary HIV counselling and testing among men in Ethiopia: a cross-sectional survey.

BACKGROUND: Voluntary HIV counselling and testing (VCT) is one of the key strategies in the HIV/AIDS prevention and control programmes in Ethiopia. However, utilization of this service among adults is very low. The aim of the present study was to investigate factors associated with VCT utilization among adult men since men are less likely than women to be offered and accept routine HIV testing. METHODS: The study utilized data from the Ethiopian Demographic Health Survey (EDHS) 2005, which is a cross-sectional survey conducted on a nationally representative sample. Using cluster sampling, 6,778 men aged 15-59 years were selected from all the eleven administrative regions in Ethiopia. Logistic regression was used to analyze potential factors associated with VCT utilization. RESULTS: Overall, 21.9% of urban men and 2.6% of rural men had ever tested for HIV through VCT and most of them had learned their HIV test result. Having no stigmatizing attitudes toward people living with HIV/AIDS was found to be strongly and positively associated with VCT utilization in both urban and rural strata. In rural areas HIV test rates were higher among younger men (aged ≤44 years) and those of higher socio-economic position (SEP). Among urban men, risky sexual behaviour was positively associated with VCT utilization whereas being Muslim was found to be inversely associated with utilization of VCT. Area of residence as well as SEP strongly affected men's level of stigmatizing attitudes toward people living with HIV/AIDS. CONCLUSIONS: VCT utilization among men in Ethiopia was low and affected by HIV/AIDS-related stigma and residence. In order to increase VCT acceptability, HIV/AIDS prevention and control programs in the country should focus on reducing HIV/AIDS-related stigma. Targeting rural men with low SEP should be given first priority when designing, expanding, and implementing VCT services in the country.