Serai D Rakgoasi (PhD) Gofaone Kgosidintsi University of Botswana Department of Population Studies. Extended Abstract: Introduction & Background

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1 Knowledge of HIV Status and Sexual & HIV Risk Behaviour in Botswana: Does knowing one s HIV Status Translate into Reduced Sexual and HIV Risk Behaviour? Serai D Rakgoasi (PhD) & Extended Abstract: Gofaone Kgosidintsi University of Botswana Department of Population Studies Introduction & Background This paper investigates the impact of knowledge of HIV status on sexual and HIV risk behaviors in Botswana. Botswana s HIV/AIDS epidemic is well documented in the literature. According to the latest available statistics, HIV prevalence in 2008 was 17.6 percent, compared to 17.1 per cent in 2004, and this prevalence was significantly higher among females (20.4%) than males (14.2%) (CSO, 2008). According to the same statistics, HIV incidence rate in 2008 was 2.9 per cent, slightly higher among females (3.5%) than males (2.3%). According to Botswana s antenatal care sentinel surveillance, HIV infection rates have increased form just over 10 per cent of women aged years in 1992, to almost a third in 2001 and increased further to 36 per cent in In 2002, in response to the escalating infection rates, Botswana enacted one of the first comprehensive and freely accessible HIV prevention, treatment and care programs of most Southern African countries. These programs, which are being delivered through Botswana s highly modern and accessible health infrastructure, are accessible to even the most rural corners of the country. However, despite the high infection rates and highly accessible and free HIV prevention, treatment and care services, the rate of utilization of these services has historically failed to reflect neither the seriousness of the epidemic or the fact that the services are offered free of charge. In response to the poor uptake, in early 2004, the government introduced a policy of routine HIV testing in which all patients are tested for HIV when they visit their doctor unless they opt out. A major aim of this approach to HIV testing, which was formally recommended in June 2004 by UNAIDS and the World Health Organization, was to increase uptake of HIV testing and treatment, and to reduce HIV-related stigma by treating the HIV test like any other routine medical procedure. 1

2 A major component of Botswana s HIV prevention strategy is the provision of accurate information and knowledge on HIV prevention and transmission, as well as the promotion of voluntary and routine HIV counseling and testing. Available evidence suggests that despite the high prevalence rates which are sustained by the fact that ARV s have been successful in keeping those who are infected, alive for longer, new HIV infections are beginning to abate. The decline in infection rates is generally attributed to HIV /AIDS IEC programs, which have provided accurate information and education on HIV prevention and transmission, as well as the promotion of voluntary and routine HIV counselling and testing. Correct and sufficient knowledge of HIV prevention and transmission increases the efficacy of individuals to engage in behaviour that minimises sexual risk of HIV infection, such as use of condoms and keeping fewer sexual partners, while HIV counselling and testing and subsequent knowledge of one s HIV status empowers individuals to avoid transmission to others (if they are infected) or infection (if they are not infected), as well as inculcation of tolerant and open attitudes and beliefs not only about HIV prevention, treatment and care services, but also attitudes towards people living with and affected by HIV/AIDS (PLWHA). Most of the available research and literature on knowledge of HIV focuses on the association between knowledge of various aspects of the HIV epidemic and its impact on sexual and HIV risk practices (see DiClimente et al., 1990; McKinnon 1996; Mawar et al., 1997; Bazargan et al., 2000; Fako 2006, Hua et al., 2011). However fewer studies (Selwyn et al., 1989; Kalichman & Rompa, 2000; Kalichman & Simbayi, 2003; Scott-Sheldon et al., 2010) have sought to isolate the impact of HIV testing or knowledge of one s HIV status on sexual and HIV risk behaviours. Thus, the impact of knowledge of one s own HIV status on the sexual and HIV risk behaviours of individuals has not been as extensively researched and therefore understood, compared to the impact that knowledge of various aspects of the HIV has on sexual and HIV risk practices. Voluntary and routine HIV testing are an integral part of Botswana s HIV prevention strategy, thus it become imperative that their impact on sexual and HIV risk behaviours be studies and understood. So far there is no evidence of research on the impact of knowledge of HIV status on sexual practices in Botswana. 2

3 Objective: This paper investigates the impact of knowledge of HIV status on respondent s sexual and HIV risk behaviours in Botswana. It seeks to establish if individuals who know their HIV status have significantly different sexual and HIV risk behaviours and practices compared to those who do not know their status. Data: Data from the Botswana AIDS Impact Survey III (2008) are used to investigate the association between knowledge of HIV status and sexual and HIV risk behaviour. This survey is the thirds in a series of nationally representative HIV/AIDS impact surveys conducted in Botswana since Methods Frequencies and cross tabulations with chi-square are used to investigate the bivariate relationship between knowledge of HIV status and sexual and HIV risk behaviours. Binary logistic regression is also used to further explore the impact of knowledge of HIV status on sexual and HIV risk behaviour. The major independent variable is Knowledge of HIV status, which is divided into four categories, namely: 1) Individuals who know they are HIV positive 2) Individuals who do not know they are HIV positive 3) Individuals know they are HIV negative, and finally 4) Individuals who do not know they are HIV negative. Control variables include age, sex, education, place of residence and religious affiliation. The dependent variable are: Number of current sexual partners, Number of sexual partners during the past year and condom use consistency Results: The results show that 60.1 per cent of respondents have tested for HIV at least once, and that 62.5 per cent of those who tested, did so during the year leading to the survey. The test results of the anonymous HIV test conducted during the survey indicate that 17.6 per cent of respondents who consented to test we HIV positive. Close to a fifth (18.7%) of respondents knew they were 3

4 HIV positive; 3.6% didn t know they were HIV positive; 42.1% knew they were HIV negative and 35.7% were HIV negative and didn t know it. The percentage of respondents who knew they were HIV positive was significantly higher among women compared to men (22.9 versus 13.3 per cent). Age, education and place of residence also showed significant association with knowledge of one s HIV status. Logistic regression gross model results show that knowing that one is HIV positive was associated with a 39 per cent reduction in the likelihood of reporting having had sexual intercourse with two or more people during the 12 months before the survey; a 30 per cent reduction in the likelihood of having multiple concurrent partners. Knowing that one was HIV positive was associated with a 34 per cent reduction in the likelihood of reporting inconsistent condom use with their last three sexual partners, compared to respondents who are HIV negative and didn t know it. The odds of being inconsistent condom users were not significantly different between respondents who didn t know they were HIV positive and the reference group. The logistic regression net effects model shows that after controlling for cofounding variables, knowing that one is HIV positive was associates with a 10 per cent reduction in the odds of having had sex with two or more people during the year leading to the survey, and a 3 per cent reduction in the odds of reporting two or more current partners. Knowing one s HIV positive status is associated with a 41 per cent reduction in the likelihood of reporting inconsistent condom use, while knowing one s HIV negative status was also associated with a 24 per cent decline in the likelihood of inconsistent condom use, compared to respondents who are HIV negative and didn t know it. However, those were HIV positive and didn t know it were 1.4 times more likely to report having had sex with two or more people during the year leading to the survey; and 1.5times more likely to have two or more current sexual partners, compared to respondents who were HIV negative and did know it. The odds of being inconsistent condom users were not significantly different between respondent who were HIV positive and didn t know it and the reference group. On the other hand, respondents who knew they were HIV negative were marginally more likely (8%) to report having had sex with two or more people during the year leading to the survey, and 9 per cent more likely to report having two or more current sexual partners compared to respondents who were HIV negative and didn t know it. However, knowing that one was HIV 4

5 negative was associated with a 30 per cent reduction in the likelihood of being inconsistent condom users with their last three sexual partners. Discussion Promotion of accurate and sufficient knowledge of HIV prevention and transmission and HIV VCT are key components of Botswana s HIV/AIDS prevention strategy. While the association between knowledge of HIV prevention and transmission has subjected to empirical research, so far there is a dearth of knowledge on the impact of VCT on sexual and HIV risk behaviours. The results of this analysis suggest that knowledge of one s HIV status, just like knowledge of HIV transmission and prevention reduces the likelihood of risky sexual and HIV risk practices. Specifically, knowing that one was HIV positive or negative, was associated with a reduction in the likelihood of having sex with two or more people during the year leading to the survey; reporting multiple concurrent partnerships and being inconsistent condom user. The results of this analysis suggest that the promotion of HIV VCT, in addition to provision of information on HIV prevention and transmission, has the potential to reduce sexual and HIV risk behaviours in Botswana. Despite the contribution of knowledge of HIV status to the reduction in sexual and HIV risk behaviour, there are however, worrying signs of potential for sexual disinhibition associated with knowledge of an HIV negative status as shown by the slight but statistically significant tendency to report more sexual partners during the year leading to the survey and multiple concurrent sexual partnerships. Thus, any efforts to promote safe sexual and HIV risk behaviours, should constantly be alert of the potential towards sexual dis-inhibition associated with other HIV risk mitigation strategies such as safe male circumcision 5

6 Bazargan M., Kelly E.M., Stein J.A., Husaini B.A. & Bazargan S.H., 2000 Correlates of HIV Risk- Taking Behaviors Among African-American College Students: The Effect Of HIV Knowledge, Motivation, And Behavioral Skills. Journal of National Medical Associations, 92(8): Central Statistics Office, 2008 Preliminary Results: Botswana AIDS Impact Survey III, Government o Botswana, Gaborone DiClemente, R.J., Forrest, K.A.; Mickler, S., 1990 College Students' Knowledge and Attitudes about AIDS and Changes in HIV-Preventive Behaviors, AIDS Education and Prevention, Vol 2(3), 1990, Fako T.T Social And Psychological Factors Associated with Willingness to Test for HIV Infection Among Young People in Botswana, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, Special Issue Volume 18, Issue 3 Hua Zhang, Meizhen Liao, Xijuan Nie,Rongjian Pan, Chuangxin Wang, Shiman Ruan, Changqing Zhang, Xiaorun Tao, Dianmin Kang & Baofa Jiang, 2011 Predictors of Consistent Condom Use based on The Information-Motivation-Behavioral Skills (IMB) Model Among Female Sex Workers in Jinan, China, accessed online at Kalichman S.C. & Simbayi L.C. HIV Testing Attitudes, AIDS Stigma, and Voluntary HIV Counselling and Testing in a Black Township in Cape Town, South Africa, Journal of Acquired Immune Deficiency Syndromes Kalichman SC, Rompa D., 2000 Functional Health Literacy is associated with Health Status And Health- Related Knowledge in People Living With HIV-AIDS, Journal of Acquired Immune Deficiency Syndromes 25(4): ] Lori A J Scott-Sheldon L.A., Carey M.P., Carey K.B., Cain D., Vermaak R., Mthembu J. Harel O., Simbayi L.C., Kalichman S.C, 2011 Impact Of HIV Testing on Sexual Health Communication in South Africa, Sex Transmission Infection 87: Mawar N, Mehendale S, Thilakavathi S, Shepherd M, Rodrigues J, Bollinger R, Bentley M., 1997 Awareness & Knowledge of AIDS & HIV Risk among Women Attending STD Clinics In Pune, India, The Indian Journal of Medical Research [1997, 106: ] 6

7 McKinnon K, Cournos F, Sugden R, Guido JR, Herman R., 1996 The Relative Contributions Of Psychiatric Symptoms And AIDS Knowledge To HIV Risk Behaviors Among People With Severe Mental Illness, The Journal of Clinical Psychiatry 57(11): ] Selwyn P.A., Carter R.J., Schoenbaum E.E., Robertson V.J., Klein R.S., Rogers, M.F., 1989 Knowledge of HIV Antibody Status and Decisions to Continue or Terminate Pregnancy Among Intravenous Drug Users, Journal of American Medical Association;261(24):