|Year : 2013 | Volume
| Issue : 2 | Page : 108-114
Stigma and underutilization of facility-based sexually transmitted infection services undermine human immunodeficiency virus testing in rural communities of Rivers State, Nigeria
Charles I Tobin-West1, Ayebatari M Lawson2
1 Department of Preventive and Social Medicine, University of Port Harcourt, Port Harcourt, Nigeria
2 Community Medicine Department, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
|Date of Web Publication||26-Jul-2013|
Charles I Tobin-West
Department of Preventive and Social Medicine, University of Port Harcourt, Choba, Port Harcourt
Source of Support: None, Conflict of Interest: None
Context: Human immunodeficiency virus (HIV) testing is a critical step in limiting the spread of the virus and ensuring access to prevention, treatment, care and support. Aims: The study examines the consequences of stigma and underutilization of facility-based sexually transmitted infection (STI) services on the uptake of HIV testing in rural communities of Rivers State, Nigeria, in other to provide information necessary to address the problem. Materials and Methods: A cross-sectional study was conducted between the 1 st and 30 th July 2011 among men and women of reproductive age living in rural communities of Rivers State, Nigeria, using a multistage sampling technique. Data were analyzed using the Epi-info version 6.04d, with confidence limit set at 95%. Results: A total of 596 participants: 270 men (45.3%) and 326 women (54.7%) were interviewed. Their mean age was 26.59 ± 7.77 years. Only 226 (37.9%) of them had ever tested for HIV. Most had stigmatizing attitudes towards HIV positive persons, 164 (71.6%) and had not tested for HIV (χ2 = 8.85, df = 1, P = 0.003). Of those who reported STIs, only 45.7% received treatment from a health facility, against 188 (54.3%) who did not. Consequently, only 90 (67.2%) of them were tested for HIV compared to 44 (32.8%) who received treatment from informal care providers (χ2 = 8.41, df = 1, P = 0.000). Conclusions: Stigma and low patronage of facility-based STI services undermine HIV testing. Anti-HIV campaigns must be consciously designed to prevent and correct stigmatization, emphasize the relationship between HIV and STIs and the significance of seeking appropriate care from health facilities.
Keywords: Human immunodeficiency virus counseling and testing, Nigeria, rivers state
|How to cite this article:|
Tobin-West CI, Lawson AM. Stigma and underutilization of facility-based sexually transmitted infection services undermine human immunodeficiency virus testing in rural communities of Rivers State, Nigeria. Int J Health Allied Sci 2013;2:108-14
|How to cite this URL:|
Tobin-West CI, Lawson AM. Stigma and underutilization of facility-based sexually transmitted infection services undermine human immunodeficiency virus testing in rural communities of Rivers State, Nigeria. Int J Health Allied Sci [serial online] 2013 [cited 2019 Nov 12];2:108-14. Available from: http://www.ijhas.in/text.asp?2013/2/2/108/115686
| Introduction|| |
The global burden of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) remains a cause for concern, especially in the developing countries of sub-Saharan Africa, where two-thirds of all infected persons live and three quarters of global deaths occur.  The epidemic is a threat to the realization of key developmental goals, including the Millennium Development Goals in most of these countries. Nigeria as one of the countries most affected by the epidemic in terms of the actual number of persons infected with the virus, developed of a National Strategic Frame-work with a target to reach 80% of sexually active adults and 80% of most at-risk populations with HIV counseling and testing services by 2015. , This is because HIV testing is recognized as a critical step in limiting the spread of the virus and ensuring universal access to prevention, treatment, care, and support.  Individuals often perceive themselves as low-risk for HIV infection. They often do not see the need to take precautionary measures to protect themselves from getting infected or getting to know their HIV-status, even when they engage in high-risk behaviors.  Furthermore, the association of HIV infection with socially unacceptable behaviors of promiscuity and sex work,  heighten their fear of being labeled promiscuous, and thus prevents them from HIV testing, disclosing their HIV status and even seeking treatment. , Therefore, encouraging people to test voluntarily before they develop symptoms of infection has remained a major challenge. Even where HIV testing programs are integrated into other health care services such as sexually transmitted infection (STI) services, under-utilization of these services tend to greatly undermine uptake of HIV testing.  As a result, the HIV Counseling and Testing (HCT) uptake in Nigeria has remained low. In 2007, it was as low as 8% in some regions of the country.  The attendant consequences are quite obvious. They include delay in diagnosis, high risk transmission to others, , and late presentation which has shown to account for as many as 77% of AIDS-related death globally.  The relevance of early case findings through HIV testing therefore, cannot be overemphasized. It is important to address behavioral barriers limiting global efforts aimed at improving access and acceptability of these HIV control services.
The aim of this study is to examine the consequences of stigma and underutilization of facility-based STI services on the uptake of HIV testing services in rural communities of Rivers State, Nigeria. The results will be useful in designing effective, behavioral change interventions for reducing HIV/AIDS related morbidity and mortality.
| Materials and Methods|| |
The study was carried out in Rivers State, Nigeria, located in the oil rich Niger Delta region which belongs to the South-South geo-political zone. The state has a population of about 5.2 million and is made up of as many as 20 ethno-linguistic groups distributed within 23 Local Government Areas. Rivers State has one of the largest economies in Nigeria, mainly because of its crude oil deposits. Approximately 72% of the population is rural, while 28% is urban.  The state is arbitrarily divided into riverine communities whose predominant occupation is fishing and upland communities whose predominant occupation is farming. There has been a rising trend of HIV/AIDS and other sexually transmitted diseases within the state which has been attributed to the high incidence of transactional sex and risky sexual behavior due to influx of highly mobile young, sexually active populations into the oil rich region.  Currently, the state has a total of 183 HCT centers located within primary, comprehensive and secondary health facilities.  The study was carried out in rural communities in the state located within a 5 km radius from a HCT centre. The study was a cross-sectional study where persons who had undergone HIV testing were compared with those who had not to determine if there were any differences in the occurrence of any behavioral factors. The study population consisted of men and women in the reproductive age group between 15 years and 54 years living in rural areas, within a 5km radius or 30 minutes walking distance from a HCT centre. The HCT centre must have been functional for 3 years or more and STI services were rendered free of charge.
The following assumptions were made:
Proximity to a HCT centre will eliminate influence of distance on access.
Services rendered free of charge will eliminate economic barriers to access.
Persons resident in an area for up to 3 years would have had ample time to have visited the health facility at least once.
A minimum sample (n) of 561 was considered adequate for the study based on the formula for descriptive studies,  : n = Z 2 pq/d 2 , where, n = Minimum sample size, Z = Normal standard deviate 1.96 at 95% confidence level, P = 21% of persons stigmatized because of HIV positive status,  q = 1-p, d = Error margin of 5%, adjustments made for a Design Effect (DEFT) = 2 and non-response rate of 10%.
n = Z 2 pq/d 2
n = 1.96 2 × 0.21 × 0.79/0.05 2 = 254.93
With adjustments for:
DEFT of 2 = 254.93 × 2 = 509.86
Non-response rate of 10%=509.86 + 50.99
n = 560.85.
However, all 596 questionnaires retrieved from the field were analyzed.
A multistage sampling design was used to select the study participants. A list of HCT centers in Rivers State was obtained from the Rivers State Agency for the Control of HIV/AIDS and was used to create a sampling frame.
Three HCT centers were randomly selected from the frame by simple random sampling from existing 183 in the entire State. The facilities selected were Comprehensive Health Centre, Degema, Pope John Paul II Catholic Hospital Eeken and General Hospital Ahoada.
All communities within a 5 km radius of each of these canters were mapped out using locality maps obtained from the State Ministry of Planning and Urban Development. The list of the Census Enumeration Areas (EAs) for each eligible community was obtained from the State office of the National Population Commission. It was used to create a sampling frame of 600 EAs out of which 30 were selected by simple random sampling using a table of random numbers.
600 questionnaires were evenly distributed amongst the 30 EAs i.e., 20/EA. A cluster sampling method was used to select eligible participants for the households. The first house and household was determined by assuming a central location in a community selected for the study and by "spinning a pen'' to determine the direction of the first house and all eligible targets in the households who consented to partake in the study. The next house to be surveyed was the next consecutive house, until the sample size for that EA was completed.
Data collections were carried out over a period of 1 month, 1 st to 30 th July 2011 by previously trained data collectors. Data were collected using a pre-tested and standardized interviewer administered questionnaires adapted from the Joint United Nations program on HIV/AIDS,  Measure evaluation (MEASURE)  and Family Health International  survey tools for accessing behavioral factors that influence HIV testing and health seeking behaviors.
Section 1: Demographic data and history of testing
Information on age, sex, marital status, educational history and occupation was recorded. Prospective recruits were also assessed for eligibility based on their age and the duration of residency within the community.
Participants were asked if they had tested for HIV previously or not.
Those who had tested were asked to select one option from a list of options that describes the reasons why they tested.
Section 2: Knowledge about HIV
Respondents were asked a set of nine questions about their knowledge of HIV/AIDS transmission. They were then assigned a score based on the number of question they answered correctly. A correct answer attracted a score of one (1) and a wrong answer, zero (0). The maximum score was nine (9). Respondents were then classified as having good knowledge if their total score was greater than or equal to five (5) or poor knowledge if their total score was less than five (5). Respondents were also asked to select one option that best describes their source of information about HIV.
Section 3: HIV risk assessment (risk behavior)
Respondents were asked a set of questions that assessed their HIV risk. The questions were based on their risk perception for contracting the HIV infection. It consisted of questions regarding their sexual activities and history of blood transfusion. Questions were weighted and assigned scores to determine actual risks. The maximum score was ten (10). Those with total scores greater than or equal to five (5) were classified as "high-risk'', those with scores less than five were classified as "low-risk''.
Section 4: Stigma
Part A: Stigmatizing attitudes
Respondents were required to express their agreement or disagreement to set of questions that qualified as stigmatizing statements against HIV positive persons. The questions were aimed at assessing their attitude towards HIV positive person. Each question was given a score as follows: Agree = 2, disagree = 1, indifferent = 0. Those who did not respond or who were indifferent were excluded. The maximum score was ten (10). Those who had total scores greater than five (5) were classified as "High stigmatizing tendencies'' whilst those with scores less than 5 were classified as "Low stigmatizing''.
Part B: Observed enacted stigma
Respondents were asked a set of questions that assessed if they had ever observed how HIV positive persons were ill-treated in their community as a measure of their level of awareness of the existence of stigma within the communities. Each question was given a score (Yes - 2, No-1, indifferent- 0). Those who did not respond or who were indifferent were excluded. The maximum score was ten (10). Those who had total scores greater than or equal to five (5) were classified as having a "High awareness'' whilst those with scores less than 5 were classified as having a "Low awareness''.
Section 5: Choice of care provider for STI treatment
Respondents were asked if they had symptoms of any STI in the last 12 months and where they sort treatment. Choice of treatment provider for those who had a history of symptoms and why was recorded.
Data were analyzed using the Epi-info version 6.04 statistical Software package. Chi-square tests were performed and used to determine levels of statistical significance set at P = 0.05.
Ethical clearance for the study was obtained from the Research and Ethics Committee of the University of Port-Harcourt Teaching Hospital, while permission to administer the study tools was obtained from the Local Government Authorities and community leaders. Furthermore, Informed consent was obtained from each participant after thorough explanation of aim and benefits of the study.
| Results|| |
Demographic characteristics of respondents
A total 596 interviews were successfully conducted out of 600 scheduled, given a response rate of 99.3%. They consisted of 270 men (45.3%) and 326 women (54.7%). They were aged between 15 years and 54 years. The mean age was 26.59 ± 7.77 years. Most of the respondents 375 (62.9%) were single and had secondary education. They were mainly unemployed 48.8%, but 28.7% were engaged in petty trading [Table 1].
Knowledge of HIV transmission among respondents
A total of 545 (91.4%) of respondents had "good knowledge'' of the routes of HIV transmission, while only 51 (8.6%) had "poor knowledge''. The levels of knowledge in men and women were similar: 257 (95.2%) in men and 309 (94.8%) in women (χ2 = 0.08, df = 1, P = 0.781).
The most common sources of information for both men and women were similar and were from mass media 286 (48%) and peers/friends 150 (25.2%).
History of HIV testing
Of the 596 persons interviewed, only 226 (37.9%) had ever tested for HIV. They consisted of 91 (40.3%) males and 135 (59.7%) females (χ2 = 8.15, df = 1, P = 0.004). The most common reasons for HIV testing among men and women were significantly different. While the mandatory requirement during surgery or other illnesses was the major reason for testing among men, "Routine testing'' during prenatal care was the most common reason for testing among women (χ2 = 23.519, df = 4, P = 0.000).
Stigma and HIV testing
The survey showed that 229 (38.4%) of the respondents had strong stigmatization tendencies towards HIV positive persons compared to 367 (61.6%) with low stigma outlook. Most with such high stigma tendencies, 164 (71.6%) had not tested for HIV themselves when compared to 206 (56.1%) with low stigma attitudes (χ2 = 8.85, df = 1, P = 0.003). Observed enacted stigma was however found to be low: Only 4.4% of men and 7.4% of women ever observed discrimination against persons living with HIV [Table 2].
Choice of care provider for treatment of STI and HIV testing
A total of 346 (58.2%) of respondents had symptoms of an STI in the last 12 months preceding the survey. The most common symptoms were virginal discharge among women (68%), and urethral discharge among men (44%). Others were sore or rash on the penis or the vulva and vagina. This was reported by (10%) of the men and 3% of the women. Of these, only 179 (51.7%) of them sort treatment in a health facility, while the rest 167 (48.3%) received treatment from the informal health care providers such as chemist shops, herbalist etc., History of STIs was equally high, 346 (58.2%) and only 45.7% (158/346) of those with such history had sort treatment in a health facility against the rest 188 (54.3%) who received treatment from informal health care providers. Only 8 (5.6%) of all those who received treatment from the informal care providers tested for HIV compared to 90 (67.2%) who received treatment from health facilities (χ2 = 5.52, P = 0.019 [Table 2].
| Discussion|| |
Most of the respondents in the study were young people between the ages of 15 years and 25 years, single and sexually active. People in this age bracket are very vulnerable to HIV infection as they often engage in risky sexual behaviors.  There is therefore need for HIV testing among them. Knowledge of the routes of HIV transmission was high amongst them. Their fairly good educational background might have assisted in getting HIV-related information across to them through the mass media. However, despite the seemingly impressive awareness about HIV/AIDS, only about a third of the respondents had undergone a HIV test, including those categorized as high-risk. This is particularly worrisome because of the risk of late diagnosis of the infection with unfavorable outcomes. Several studies however, support this finding that knowledge does not necessarily produce a correct self-risk assessment or reduction in risky sexual behavior with regards to HIV/AIDS. ,,,
The study also revealed a high prevalence of stigmatizing attitudes towards HIV positive persons among respondents. Ironically however, most of those with such stigma tendencies had not tested for HIV themselves. Stigma makes individuals reluctant to access HIV testing, treatment and care, thereby compromising attempts to fight the epidemic in general. This substantiates findings that stigma constitutes a barrier and exerts negative effects on individual's acceptance of a HIV test. , In the words of Ban Ki Moon, the United Nations Secretary General: "Stigma remains the single most important barrier to public action. It is a main reason why too many people are afraid to see a doctor to determine whether they have the disease, or to seek treatment if so. It helps make AIDS the silent killer, because people fear the social disgrace of speaking about it, or taking easily available precautions. Stigma is a chief reason why the AIDS epidemic continues to devastate societies around the world".  It leads to negative reactions towards HIV positive persons and needs to be corrected if HIV prevention and control interventions must succeed.
Over half of our respondents had reported a history of STI in the last 1 year preceding the study. This was an indication of the high level of sexual networking and unprotected sexual activities existing in the rural communities. Considering the association and the "epidemiological synergy'' between HIV and STI, , this finding has strong implications for HIV transmission within the communities. Surprisingly however, many of those respondents with a history of an STI received treatment from the patent medicine vendors and therefore missed the opportunity to be tested for HIV and the benefits of early case detection. The major reason adduced for preference of patent medicine vendors was that their services were faster, cheaper and more confidential than the health care facilities albeit of lower quality. This finding is similar with that reported in other African countries, where most persons with STIs sort treatment from the informal healthcare providers. ,
It suggests therefore, that establishing health care facility-based interventions without proper re-orientation of the beneficiaries may not yield the desired results. A clear understanding of how people make decisions about their health and their preferred choices of care providers needs must be taken into consideration before establishing such facilities and programs.
A limitation of this study however, was that it was a cross sectional study and so no temporal association can be inferred.
| Conclusion|| |
Stigma and low patronage of facility based STI services for the treatment of STIs constitutes an obstacle to HIV testing in rural communities. HIV awareness campaigns must consciously be designed to prevent and correct stigmatization and emphasize the association between HIV/AIDS and STIs and the importance of seeking timely and appropriate treatment from health facilities instead of patronizing medicine vendors or other Informal health care providers. More studies are needed to determine if Patent medicine dealers can also be trained to offer HIV counseling and testing to improve uptake in rural communities.
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[Table 1], [Table 2]