HIV Sero-discordance, sexual and practice of preventive behavior against HIV Acknowledgements

Transcription

1 Acknowledgements First of all, my deepest gratitude goes to my advisor Dr. Gail Davey who tirelessly and patiently assisted me in various aspects of this work starting from proposal development I would also like to extend my thanks to EPHA- CDC project for funding this thesis work. My appreciation also goes to all my friends who shared their expertise during the statistical analysis of this work and encouragement. Finally, I take this opportunity to extend my thanks to all study participants and data collectors who participated in this study. i

2 Table of contents Page Acknowledgement...i Table of contents...ii List of tables...iv List of figures...vi Acronyms....vii I. Introduction Background Literature review Global and regional burden of HIV National HIV/ AIDS situation Global and regional sero-prevalence & discordance National HIV sero-prevalence and sero-discordance Determinants of HIV sero-prevalence and sero-discordance Sexual and practice of preventive behavior Statement of the problem II. Objective General Objective Specific Objective III. Materials and Methods Study area and population Sample Size and Sampling Technique Study Design Source/ study population Data Collection procedure Lab. Procedures Operational definitions Data Analysis Data quality management Ethical Consideration IV. Results ii

3 V. Discussions VI. Strengths and limitations of the study VII. Conclusions and Recommendations VIII. References iii

4 List of tables Page Table 1: Sociodemographic characteristics of study subjects attending VCT in Bahir Dar, Ethiopia, Table 2: Prevalence of sero-discordance across socio-demographic variables in Bahir Dar, Ethiopia, Table 3: Prevalence of premarital sexual activity and sexual behavior among never married couples in Bahir Dar, Ethiopia, Table 4: Comparison of sexual behavior between male and female study couples in Bahir Dar, Ethiopia, Table 5: Multivariate logistic regression indicating factors association with premarital sex among never married couples in Bahir Dar, Ethiopia, Table 6: Association between socio-demographic variables with age of sexual debut, Bahir Dar, Ethiopia, Table7: Beliefs and sexual behavior of respondents, Bahir Dar, Table 8: Association between socio-demographic characteristic and HIV Sero-positivity in Bahir Dar, Ethiopia, Table 9: Association between sexual behavior and HIV Sero-positivity in Bahir Dar, Ethiopia, Table 10: Multivariate analysis showing factors association with HIV Sero-positivity in Bahir Dar, Ethiopia, Table 11: Factors associated with HIV Sero-discordance in Bahir Dar, Ethiopia, iv

5 List of figures Page Fig.1: Reasons mentioned for starting sex among premarital couples in Bahir Dar, Ethiopia, Fig. 2: VCT Scheme of testing preferred in premarital couples in Bahir Dar, Ethiopia, Fig. 3: Type of first sexual partner among premarital couples in Bahir Dar, Ethiopia, Fig. 4: Number of sexual partners other than current fiancé in the past one year in Bahir Dar, Ethiopia, v

6 Acronyms AIDS ANC AOR ARV BCC BSS CHCT CI COR E-DHS EPHA FSWs HAPCO HIV HIV CT IEC MSM MOH NACP NACS NGO PLWHA PMTCT SD SNNPR SPSS Acquired Immunodeficiency Virus Antenatal Care Adjusted Odds Ratio Antiretroviral drugs Behavioral Change Communication Behavioral Surveillance Survey Couple HIV Counseling and Testing Confidence Interval Crude Odds Ratio Ethiopian Demographic Health Survey Ethiopian Public Health Association Female Sex Workers HIV/AIDS Prevention and Control Office Human Immunodeficiency Virus HIV counseling and testing Information Education Communication Male having Sex with Male Ministry of Health National AIDS Control Program National HIV/AIDS Council Secretariat Non-Governmental Organization People living with HIV/AIDS Prevention of Mother to Child HIV Transmission Standard deviation Southern Nations and Nationalities people s Region Statistical packages for Social Science Studies vi

7 I. Introduction 1.1. Background Premarital screening is defined as a test in which couples intending to be married are tested for genetic, infectious and blood-transmitted diseases to prevent any risk of transmitting the disease to their children or partner. A couple is said to be sero-discordant for HIV if one test is positive and the other negative for HIV. Outside the United States and Western Europe, the human immunodeficiency virus (HIV) epidemic is largely heterosexual and is growing. Sero-positive individuals who do not disclose their status to sexual partners are often portrayed as dangerous outsiders. The public health significance of nondisclosure, however, depends on both its prevalence and the riskiness of the behaviors that occur without disclosure that is, the extent to which sex without disclosure is unprotected sex between sero-discordant partners. Major epidemic foci of HIV/ AIDS infection are presently occurring in Africa and the Caribbean. The epidemiological features of HIV infection in Africa are strikingly distinct from those in Europe. Heterosexual activity is the major mode of transmission, as illustrated by a female to male case ratio approaching 1:1. The disease is also spread by blood transfusions, prenatally from infected mothers to their neonates, and probably also by contaminated injections (1). Reported seroprevalence rates for HIV antibody in the general population of sub-saharan Africa vary between 3 and 20%, and between 20-35% in studies of those presenting to VCT services (2). Communities with high HIV prevalence rates have higher rates of concordant positive and discordant couples. The percentages of couples who are concordant negative, concordant positive, and discordant will vary by the prevalence of HIV in the country, within communities in a country, and by service settings within communities, such as those in urban or rural settings, PMTCT settings, VCT centers, and TB clinics, among others. In generalized epidemics, many infections occur within marital and cohabiting unions either because of prior infection by one partner or infidelity within marriage. The HIV-negative partners in discordant couples are at very high risk of contracting HIV if the couple does not take steps to protect the HIV-negative partner. Transmission risk is high among steady discordant 1

8 couples who do not take preventive measures such as using condoms than concordant negatives (3). Particular difficulties exist for discordant couples in adopting these changes in behavior. Once diagnosed, the HIV sero-positive individuals must disclose their status to their partner and alert them to their need for testing. This leads to the awareness of sero-discordance. To reduce risk, the approaches such as ABC (abstinence, being faithful, and using condoms) may not be appropriate. Being faithful will not decrease HIV risk transmission and may not be easy to adopt. Abstinence and condom use require the agreement of both partners, who may not have equal negotiating positions, with societal pressure to have children and gender inequality making it difficult for both, but particularly the women, to adhere to such measures (3). 2

9 1.2. Literature Review Global and regional burden of HIV The HIV pandemic remains the most serious of infectious disease challenges to public health. Although Global HIV percentage prevalence has been estimated to have reached a plateau since 2001, continuing new infections (even at a reduced rate) contribute to the estimated number of persons living with HIV, which stands at an estimated 33.2 million [ million] a reduction of 16% compared with the estimate published in 2006 (39.5 million [ million]), but greater in absolute terms than ever before. Global HIV incidence probably peaked in the late 1990s- at over 3 million new infections per year, and was estimated to be 2.5 million [ million] new infections in 2007 with adult prevalence of 1 %( 4) Most HIV infection in sub-saharan Africa occurs due to heterosexual intercourse between couples in a relationship. More than two thirds (68%) of all HIV-positive people live in this region where more than three quarters (76%) of all AIDS deaths in 2007 occurred. It is estimated that 1.7 million [1.4 million-2.4 million] people were newly infected with HIV in 2007, bringing to 22.5 million [20.9 million-24.3 million] the total number of people living with the virus. Unlike other regions, the majority of people living with HIV in sub-saharan Africa (61%) are women (4). Despite their importance as social contexts for sexual activity and HIV infection, couple relationships have not been given adequate attention (4). National HIV/ AIDS Situation The first HIV/AIDS cases in Ethiopia were reported in the mid-1980s. Since then, the epidemic has spread to the general population in both urban and rural areas. Ethiopia s epidemic stabilized in urban areas in , after which HIV infection levels declined slowly, notably in parts of the capital, Addis Ababa. In rural Ethiopia, where the majority of the population resides, the epidemic has remained relatively stable since HIV prevalence peaked in (5). The sixth report on AIDS in Ethiopia published in 2005 by the Federal Ministry of Health indicated a national adult prevalence of 3.5% in 2005, with an unacceptably high HIV prevalence of 10.5% in urban areas. The report also indicated the national and rural HIV prevalence for 3

10 Ethiopia has stabilized while the urban epidemic reveals a slow and gradual decline following peaks in prevalence in for national, for rural, and for urban areas (6). HIV prevalence estimate results in 2006 were 1.4% from Ethiopian Demographic and Health Survey (E-DHS) and 3.5% from ANC surveillance. In early 2007, the Federal HIV/AIDS Control Office (FHAPCO) initiated a Task Force to attempt to reconcile these two estimates with a view of establishing one single estimate. The task force estimated an overall adult prevalence of 2.1% (urban 7.7% and rural 0.9%) (7). Large regional differences in HIV prevalence exist. The prevalence of HIV/AIDS in Bahir Dar town, as estimated from the sero survey result of ANC attendants in of Bahir Dar Health center, indicated that the town has the highest sero prevalence rate (20.8 %) of the whole country. Sero surveys on HIV prevalence conducted among sex workers in Ethiopia from 1988 to 1999 showed that the prevalence in Bahir Dar town was the highest in the country and showed a progressive rise from 35.9 % in 1988 to 69.4 %in 1991 (8). In 2004, ANC based surveillance estimates HIV prevalence in Bahir Dar is 14% in Felege Hiwot Hospital and 13.5% in Bahir Dar Health Center (5). However, prevalence of HIV among couples in Bahir Dar is not known. Global and regional HIV sero-prevalence and sero-discordance among couples A prescreening data from July April 2007 in experimental study to assess the impact of HSV-2 suppression with acyclovir in reducing HIV-1 transmission among couples in which one partner is HIV-1/ HSV-2 co-infected and the other partner is HIV-1-uninfected in Eastern Africa(Kenya, Uganda and Tanzania) and Southern Africa (South Africa, Zambia; and Botswana) showed that the prevalence of stable HIV-1-discordant partnerships ranged from 8 to 31% of couples tested at each study site. Eastern and Southern African sites reported 12% and 18% HIV-1 discordance, respectively, with 15% HIV-1 discordance found across the whole study. Among all couples tested who had at least one HIV-1 infected partner, the proportion of couples which were HIV-1-discordant varied by study sites from 36-85% with an overall rate of 49% (9). Examination of premarital couples between in Nairobi, Kenya showed the prevalence of HIV infection in premarital females was 14% compared with 8% in premarital males and 15% of couples were serologically discordant. In the majority of discordant premarital 4

11 couples, it was the woman who was HIV-infected (10). In contrast, the prevalence of HIV infection among individuals referred from faith-based organizations (FBOs) in south-eastern Nigeria between January 2000 and December for mandatory prospective pre-marital HIV screening was 20.8%, 27.4% among females and14.3% among males. Infection rate was highest in the years group. Infection rate was significantly higher among females, couples with prolonged courtship (>6 months), couples with history of premarital sex, and couples with history of cohabitation (11). National HIV sero-prevalence and sero-discordance among couples According to the EDHS 2005, 89.1% of cohabiting couples in urban areas were concordant negative, 7.8% discordant and 3.1% concordant positive (6). In Addis Ababa prevalence of HIV was 25.1% among VCT attendants, while among premarital couples attending VCT the prevalence was 13.2% (12). A study in Dessie showed over all sero-prevalence of 5.8% with 9.8% discordance, 0.93% concordant positive and 88.3% concordant negative. There was a higher proportion of discordance among married (13.7%) than never married (6.2%) couples and married couples were significantly more likely to be discordant than premarital couples (13). Determinants of HIV sero-prevalence and sero-discordance To describe factors associated with a positive test among Kenyan VCT clients undergoing premarital testing, data from 19 VCT sites in Nairobi, Kisumu and Mombasa between 2001 and 2003 were examined. Those previously married (OR 1.7 [ ]); divorced (OR 1.9 [ ]); or widowed (OR 6.3 [ ]) had significantly higher rates of HIV infection than single persons. Other significant risk factors included gender, age, educational level, employment status, and coming for VCT alone (10). A retrospective study in Rakai, Uganda, to determine risk factors associated with heterosexual transmission included 415 HIV discordant couples and a comparison group of over 4,000 concordant couples. Of 415 sero-discordant couples, 55% of males and 45% of females were infected at enrollment. Ninety (22%) HIV negative partners sero-converted during the course of 5

12 the study giving an incidence rate of 11.8 per 100 person-years. The highest incidence of seroconversion occurred in couples between the ages of years, an incidence rate of 18.6% per 100 person-years, with median age of enrollment 30 years. Presence of STI symptoms and AIDS defining signs or symptoms were significantly associated with an increased risk of transmission to uninfected partner (17). A study in Gondar city among street dwellers in 2004 showed that age, sexual exposure and number of partners were associated with HIV status. Age was negatively associated with HIV infection (COR [95% CI] =0.94 [ ]). Those street dwellers that were exposed to sexual intercourse were at risk of acquiring HIV infection, so that, street dwellers with only one, or two and above sexual partners were about 18 and 29 times more likely to be infected than those that did not have any sexual partners, respectively (15). Sexual activity and Practice of preventive behavior against HIV Interventions to prevent HIV/ AIDS have tended to focus on condoms ( C ), neglecting abstinence A and faithfulness B (18). The major focus of condom-promotion strategies has been on increasing use outside marriage. Sexual intercourse is commonly initiated during adolescence. Early onset of sexual intercourse is associated with increased risk of life time prevalence of sexual partners, thereby increasing the risk of exposure to STIs including HIV/ AIDS (19). Aside from abstinence, consistent condom use is the most effective means of reducing the risk of transmitting STIs, including HIV. However, the condom, whether used for pregnancy prevention or STI prevention, has long been viewed as an undesirable method among some women and men (20). The main reason for condom use, in South Africa for example, (cited by 64% of users) was protection against both pregnancy and HIV infection (21). A study in US revealed that 42% of gay or bisexual men, 19% heterosexual men and 17% all women said they had unprotected sex without disclosing their HIV status to their partner. For gay men, 13% of sero-discordant partnerships involved unprotected anal and/ or vaginal sex with out disclosure of HIV status, compared with 9% heterosexual men s and 10% of women s sero- 6

13 discordant partnerships. About half of gay (58%), heterosexual men (46%) and women (47%) had sero-discordant sexual partners during 6 months before the interview (22). Among Chinese out-of-school youth, 60% had favorable attitudes towards premarital sex and another study in China also shows 69.3% of couples had a premarital sexual experience (19). A prospective study among couples in Lusaka, Zambia showed prior to receiving their test results, less than 3% of discordant couples reported current condom use with each other. In the year after VCT, the proportion of reported contacts with a condom increased to >80%. In contrast, in 66 concordant negative couples followed for a median of 12 months, condom use was reported in only 28% of sexual exposures (23). A retrospective study in Kinshasa, Zaire in 1991showed that 52% of currently married women had premarital intercourse. Fifty one percent of all women had intercourse before the age of 18 years. 75% of women with premarital sexual activity had intercourse before the age of 18 years (24). A study in Nigeria among never married adolescents (15-19 years) showed that 18% male and 22.2% females reported being sexually active with median age of 15 years in males and 16 years in females (25). In high prevalence areas of Africa, cohabiting couples make up a large proportion of groups at risk from HIV infection. The greatest HIV risk for women in these couples is their husband or regular partner (26). A study in KwaZulu-Natal, South Africa showed disapproval of condom use within marriage. Only 14 percent of men and 17 percent of women reported consistent or "occasional" condom use (27). A systematic review of observational studies in resource poor countries among heterosexual serodiscordant couples suggest that condom use is associated with 80% reductions in HIV transmission (3). In Ethiopia according to DHS 2005 (6) condom use in youth (15-24 years) at first sex is 1% among females and 17% in males. A study in Dessie among couples revealed condom use in the past 3 months was reported in 3.2% of all and 6.9% of discordant couples (13). Existing data on young people in Ethiopia revealed a falling age at sexual debut, increasing rate of sexual involvement and high prevalence of HIV/ AIDS (14). A study in rural Ethiopia among youth showed that 13% of premarital sex rate with median age of first sex 17 years. And more males than females involved in premarital sex (28). A study in Gondar among high school students showed 88.1% of respondents agreed that sexual intercourse should not be committed 7

14 before marriage. The mean age of sexual commencement was 16.9 ±1.6 years for both sexes (17.0± 1.3years for boys and 16.4 ±1.6 years for girls) (16). BSS 2005 showed that age at fist sex among out of school youth was 16 years (equal for both sexes) among younger youths and for the older youth, it was 18.1 years among males and 17 years among females (mean difference=1.2, p<0.01) (29). The timing of sexual debut among adolescents is influenced by a wide range of factors including: age, gender, educational level, knowledge and perceived risk of STIs, socio-economic status, peer influences (15, 25). 8

15 1.3. Statement of the problem Most of HIV transmission in Ethiopia is heterosexual. The prevalence of HIV in urban population is high with high discordance rate (7.8%). Moreover early sexual initiation and premarital sex among youth is increasing, but use of protective measures such has condom and VCT is low (6, 18, 27, 30). Although it is known that protection of uninfected partner is an acknowledged best practice in HIV prevention, it has not received much attention in the literature in determining magnitude especially among premarital couples in Ethiopia. Similarly, studies on sexual behavior of premarital couples are still scarce in Ethiopia. Assessing these issues would have valuable importance to devise interventions for premarital couples especially for those sero-negative partners. Because knowing their HIV status and sexual behaviors, it is possible to take actions to curb the spread of infection by preventing the other partner from becoming infected. Where such knowledge of infection status and sexual behavior is not available, the probability of seroconversion is high as little or no preventive action is taken, thus increasing the level of prevalence and its attendant evils. Hence, timely recognition of discordant couples or partners and their sexual behaviors will help to design behavioral and other interventions addressing premarital couples. Moreover, assessing the magnitude and sexual behavior of sero-discordance would lay basis for further biological and immunological studies to detail analyze determinant factors. The information on the magnitude and sexual behavior in premarital couples will have a greater contribution for governmental, community-based and non-governmental organizations to address the problems of and develop appropriate programs. Hence, this paper will assess the prevalence HIV sero-discordance and sexual and practice of preventive behaviors against HIV in premarital couples in Bahir Dar. 9

16 II. Objectives 2.1. General Objective: To assess HIV sero-discordance, sexual behavior and practice of preventive behavior against HIV among premarital couples attending VCT in Bahir Dar 2.2. Specific Objectives: To determine the prevalence of HIV infection among premarital couples To describe the practice of preventive measures against HIV among premarital couples To describe the sexual behavior of premarital couples and identify risk sex among couples To determine socio-demographic and behavioral factors associated with sero-discordance among premarital couples 10

17 III. Materials and Methods 3.1. Study area and population The study was conducted in Bahir Dar between January-March 2008 among premarital couples attending VCT in Bahir Dar town including governmental, private and NGO Centers. Bahir Dar is the capital of the Amhara national Regional State; located 565 Km from north-west of Addis Ababa. VCT service is provided in nine VCT centers with total eleven sites. Namely three governmental health centers, one governmental Hospital (two sites), four private higher clinics and FGAE- Bahir Dar branch (youth and clinic sites). The study includes 198 consecutive premarital couples who present for CHCT Sample Size and Sampling Technique The required sample size was determined using the formula for single population proportion of a cross-sectional survey. 2 n = z α/2 p (1-p) d 2 Where, n = required minimum sample size. p= the assumption of HIV prevalence in either of partners tested positive is taken to be 13.5% (5) Z = is a standard score corresponding to 95% CI, and is thus equal to d = is the precision, and will be taken as 5 % (0.05). Substituting the above values gives the sample size to be 180 couples. Adding 10% non-response rate gives the final sample size of 396 participants (198 couples).these study participants were sampled from all VCT sites using non-proportionate allocation technique Study Design: A cross-sectional descriptive facility based survey was conducted in Bahir Dar city to determine HIV prevalence, and sexual and practice of preventive behavior against HIV among premarital couples. 11

18 3.4. Source/ study population All premarital couples attending VCT in Bahir Dar were the source population. The study included a total of 198 premarital couples consecutively selected daily from the HIV CT center. The study participants were consecutive, consenting male and female patients who presented for HIV CT Data Collection procedure A pre-tested, structured questionnaire prepared in English and then translated in to Amharic was used to collect information on socio-demographic, socio-economic, sexual history, knowledge of STI/HIV and HIV CT and practice of preventive measures. All premarital couples who came for CHCT and hear their test results together were interviewed. The interview was conducted prior to pre test counseling. Data were collected on each participant on one to one basis in a counseling room. Each consenting participant was given a code first; then the test result was registered after post test counseling. The health professionals involved for interviewing were HIV counselors working as permanent employees of the respective health facilities. Additional two supervisors, including the principal investigator were also involved for data collection. All the data collectors were given orientation by the principal investigator on how to select the study subjects and then fill out the questionnaire in consultation with those willing to participate after verbal consent is taken. Inclusion criteria: those who consent to participate. -Who came for premarital HIV testing together Exclusion criteria: Those who married and those who refuse to participate Study variables: Independent Variable: Sociodemographic variables (age, sex, ethnicity, religion), sexual history (number of sexual partners, age at first sex, condom use, faithfulness, abstinence), knowledge about HIV/AIDS, STIs, and HIV VCT; Perceived benefit of HIV CT; Perceived risk of HIV Dependent variables:, prevalence of HIV & sero-discordance, sexual behavior and practice of preventive behavior against HIV 12

19 3.6. Lab. Procedures All consenting couples was counseled and serially tested for HIV using rapid tests in accordance with the MOH policy. According to VCT test algorism those tested negative for determine declared as negative. While those positive for determine serially tested for tie-breaker. If positive for both determine and tie-breaker declared HIV positive. However, if tested negative for tiebreaker serially tested for uni-gold. If tested positive for uni-gold taken to be HIV positive. When tested negative for uni-gold reported as inconclusive and referred to referral laboratory. All prospective premarital couples who came for premarital HIV testing together were included in the study. Each couple was approached and asked to give informed consent. Pretest counseling was provided for those who agreed to HCT. HIV post-test counseling and HIV test results was given at the subject s request Operational Definitions Concordant couple- is one where both partners have the same HIV status they are either negative or both positive. Comprehensive knowledge about HIV/AIDS Respondents were considered to have comprehensive knowledge about HIV/AIDS if they knew about the three most programmatically important HIV/AIDS prevention methods (namely abstinence, having one faithful uninfected sexual partner and consistent and correct condom use) and had no misconceptions about HIV transmission (29). Misconceptions- Respondents were considered to have misconceptions about HIV/AIDS transmission and prevention if they agreed to any of the following six incorrect statements about HIV/AIDS: a mosquito bite can transmit HIV; sharing a meal with someone who is HIV positive can transmit HIV; a healthy-looking person can t be infected by HIV; eating an uncooked egg laid by a chicken that swallowed a used condom can transmit HIV; eating raw meat (raw kitfo) prepared by an HIV-infected person can transmit HIV; and drinking local hard liquor and eating hot pepper can protect from HIV (29). No misconception (no incorrect beliefs about HIV/AIDS transmission) respondents were considered to have no incorrect beliefs about HIV/AIDS transmission if they correctly rejected statements expressing the two most common local misconceptions about HIV: eating raw meat 13

20 prepared by an HIV infected person transmits the virus and eating an uncooked egg laid by a chicken that has swallowed a used condom transmits HIV infection (29). Premarital couples: are those couples who came for premarital HIV testing reasons for a long term relationship. Risky sex: Any unprotected sex (i.e. sex without a condom) with any partner other than a regular partner Practice of preventive behavior: using preventive measures against HIV such as condom, VCT etc. Sero-discordant: Couples or sexual partners tested for HIV and have mixed sero-status (one partner positive while the other is being negative) STIs: are infections transmitted from person to person by sexual contact Data Analysis Data were entered in to a computer and analyzed using SPSS statistical soft ware. Sociodemographic data were summarized by frequency tables and summary statistics. For all statistical significance tests, the cut- off value set was p<0.05 as this is considered statistically reliable for analysis of such a study. Proportions, percentages, and graphs were used for description of the data as appropriate. Odds ratio with 95% confidence interval was used to identify practice of preventive behavior against HIV. Multivariate logistic regression analysis was used to control for the confounding variables Data quality management To keep the quality of the data: Data collectors were counselors Training and orientation about the objective and process of data collection was provided for data collectors for two days. Close supervision was undertaken during data collection. Supervisors checked each questionnaire daily. Pre-testing was done at similar health facilities. 14

21 3.10. Ethical Consideration Ethical clearance was obtained from Addis Ababa University, School of Public Health. The necessary permission to undertake the study was also obtained from regional health bureau. All the study participants were informed about the purpose of the study, their right to refuse and assured confidentiality and informed verbal consent was obtained prior to the interview. The instruments and procedures were not causing any harm to the study subjects, the community, the data collectors and supervisors involved in the survey. To ensure confidentiality, anonymous type of interview was employed, where names of the interviewee was not written on the questionnaire. Continuum of comprehensive HIV prevention, treatment and care & support were there for those HIV positive and sero-discordant partners. 15

22 IV. Results 4.1. Sociodemographic characteristics A total of 198 premarital couples were recruited in the study, however, interviews were conducted with a total of 195 premarital couples, excluding questionnaires filled partially or incorrectly. This gives a response rate of 97.9% in which the final analysis was calculated. All of non-respondents were concordant negative for HIV infection. The mean age for male and female respondents was SD & SD with a median age of 24 and 19 years respectively. About 38% of the respondents fell within the age range of years & 29.5% were aged years. The age range in males was while that of females was years. The majority of the respondents (96.7%) were from the Amhara ethnic group, and 95.6% were Orthodox Christian followers. The largest proportion of premarital couples (62.6%) was never married, followed by divorced (29.5%), widowed (4.4%) and living together (3.6%). The median numbers of years of schooling was 4 years with more than half of study participants (54.9%) having received formal education. The rest (45.1%) had no formal education. Of these, 146 (37.4%) participants were unable to read & write, while 30 (7.7%) were able to read and write (but no formal education), 34.1% attended secondary school, 14.4% primary and 6.4% tertiary school. About 16% of the participants had no job (unemployed), while 21% were students, 18.5% daily laborers, 17.9% farmers & 7.4% government employees. The socio-demographic characteristics of study participants are summarized in Table 1. Table 1: Sociodemographic characteristics of study subjects attending VCT in Bahir Dar, Ethiopia, 2008 Characteristics Male (n= 195) Female (n=195) Total (n= 390) Age group (6.7) 102 (52.3) 115 (9.5) (46.7) 58 (29.7) 149 (38.2) (19) 18 (9.2) 55 (14.1) (12.3) 9 (4.6) 33 (8.5) (5.1) 5 (2.6) 15 (3.8) (3.1) 2 (1.0) 8 (2.1) (7.2) 1 (0.5) 15 (3.8) 16

23 Religion Orthodox Christian 187 (95.9) 186 (95.4) 373 (95.6) Muslim 6 (3.1) 7 (3.6) 13 (3.3) Protestant 2 (1.0) 1 (1.0) 4 (1.0) Ethnicity Amhara 187 (95.9) 191 (98.0) 378 (96.7) Oromo 3 (1.5) 1 (0.5) 4 (1.0) Tigre 1 (0.5) 2 (1.0) 3 (0.8) Others 4 (2.1) 1 (0.5) 5 (1.3) Marital status Never married 117 (60.0) 127 (65.1) 244 (62.6) Divorced 60 (30.8) 55 (28.2) 15 (29.5) Widowed 11 (5.6) 6 (3.1) 17(4.4) Living together 7 (3.6) 7 (3.6) 14 (3.6) Educational status No formal education 80 (41.0) 96 (49.2) 176 (45.1) Primary 35 (17.9) 21 (10.8) 56 (14.4) Secondary 62 (31.8) 68 (34.9) 133 (34.1) Tertiary 16 (8.2) 9 (4.6) 25 (6.4) Occupational status Jobless 14 (7.2) 49 (25.1) 63 (16.2) Daily laborer 41 (21.0) 31 (15.9) 72 (18.5) Government employee 18 (9.2) 11 (5.6) 29 (7.4) Merchant 19 (9.7) 7 (3.6) 26 (6.7) Farmer 55 (28.2) 15 (7.7) 70 (17.9) CSW -- 1 (0.5) 1 (0.3) Driver 3 (1.5) -- 3 (0.8) House wife (8.2) 16 (4.1) Student 23 (11.8) 59 (30.3) 82 (21.0) Police 3 (1.5) -- 3 (0.8) 17

24 Health worker 2 (1.0) -- 2 (0.5) Teacher 1 (0.5) -- 1 (0.3) House maid -- 3 (1.5) 3 (0.8) Pensioner 1 (0.5) -- (0.3) Guard 3 (1.5) -- 3 (0.8) Others 12 (6.2) 3 (1.5) 15 (3.8) 4.2. HIV sero-prevalence and sero-discordance HIV seroprevalence in this study was found to be 15(3.8%) (95% CI = [ %]). The prevalence in females (5.1%) was higher than that in males (2.6%). Of all participants, 7couples (3.6%) (95% CI = [ %]) were found to be sero-discordant, 4(2.1%) concordant positive and 184(94.4%) concordant negative. Of the 7 sero-discordant couples, females were positive in 6 and males in 1. Among 5 couples where male partner was infected, 1 (20%) of the prospective female partners were HIV negative; among the 10 couples where female partner infected, 4(40%) of the prospective male partner were HIV negative. Among the different age groups, the highest prevalence (33.3%) of HIV infection was observed in age group of years. The lowest prevalence (6.7%) was observed in age groups of & 45+, while the rest age groups share13.3% each. Relatively high prevalence of sero-discordance was observed among widowed 1(16.7%) and living together partners 1(14.3%). High discordance rates were observed among widowed, literate and employed (Table 2). Socio-demographic variables had no statistical significant association in HIV sero- discordance (Table 11) Table 2: Prevalence of sero-discordance across socio-demographic variables in Bahir Dar, Ethiopia, 2008 Frequency n (%) Variables Concordant couples Discordant couples Total Marital status Never married 122 (96.8) 4(3.3) 126 (100) Divorced 55 (98.2) 1(1.8) 56(100) 18

25 Widowed 5(83.3) 1(16.7) 6 (100) Living together 6(85.7) 1(14.3) 7(100) Literacy level Illiterate 79(96.3) 3(3.7) 82(100) Literate 109(96.5) 4(3.5) 113(100) Employment status Employed 140 (95.9) 6(4.1) 146(100) Unemployed 48(98.0) 1(2.0) 49(100) 4.3: Perceived risk of contracting HIV About one third (34.4%) of the respondents feared being infected with HIV. Among the study participants, 88.8% perceived themselves to be at no or low risk of HIV infection while 11.2% considered themselves to be at moderate or high risk. There was no gender difference in risk perception (COR [95% CI] = 0.71 [ ]). Discordant and concordant positive serum outcome was more prevalent in those who perceived themselves at moderate or high risk of contracting HIV than perceived to be at no or low risk. Table 3: Prevalence of premarital sexual activity and sexual behavior among never married couples in Bahir Dar, Ethiopia, 2008 Variables Male No (%) (n=117) Female No (%) (n=127) Total No (%) (n=244) Ever had sex No 77 (65.8) 104 (81.9) 181 (74.2) Yes 40 (34.2) 23 (18.1) 63(25.8) Reasons for sexual initiation (n=63) Personal desire 26(65.0) 12(52.2) 38(60.3) Peer influence 5(12.5) 4(17.4) 9(14.3) Rape 0 2(8.7) 2(3.2) Need of experimenting sex 3(7.5) 0 3(4.8) 19

26 Love/lust 1(2.5) 3(13.0) 4(6.3) No response 5(12.5) 2(8.7) 7(11.1) No. of sexual partner in the past one year (n =63) Only one 29(72.5) 19(82.6) 48(76.2) Two and above 11(27.5) 4(17.4) 15(23.8) Ever use of condom (n=128: 64M) Never used 49(76.6) 58(90.6) 107(83.6) inconsistent use 9(14.1) 2(3.1) 11(8.6) Consistent use 6(9.4) 4(6.3) 10(7.8) Favorable attitude to premarital sex Yes 15(12.9) 4(3.2) 19(7.9) No 101(87.1) 122(96.8) 223(92.1) Decides to abstain till marriage Yes 58(76.3) 91(87.5) 149(82.8) No 9(11.8) 5(4.8) 14(7.8) Not sure 9(11.8) 7(6.7) 16(8.9) No response 0 1(1.0) 1(0.6) 4.4: Knowledge & misconceptions about HIV/ AIDS Knowledge of HIV prevention methods and absence of incorrect beliefs about HIV transmission were the two major indicators. People s beliefs or myths about HIV/AIDS play an important role in determining their attitudes towards people living with HIV/AIDS (PLWHA) and practice of preventive methods. Respondents were asked whether a healthy looking person can be infected with HIV. Hundred fifty five (39.7%) of the respondents said that could not be infected with HIV. And 22 (5.6%) of the respondents said HIV/ AIDS can be cured or prevented by vaccination. The majority of respondents, 89.2%, 76.2% and 72.6% respectively mentioned avoiding sex (abstinence), avoid sharing of used sharp instruments and faithfulness with only one uninfected partner as prevention methods against HIV/AIDS, 57.4% of the respondents said that using a 20

27 condom every time during sex protects people from getting HIV/AIDS. However, 1.8 % of the respondents said that drinking local hard liquor and eating hot pepper protect people from getting HIV/AIDS. Two hundred and five (52.6%, 54.4% male and 50.8% female) knew all three programmatically important HIV prevention methods. Amongst premarital couples, 93.6%, 85.6%, 68.2%, 16.2%, 12.3% & 2.3% respectively reported that HIV can be transmitted by unsafe sex, sharing sharp instruments, blood transfusion, eating an egg from a chicken that had swallowed a used condom, mosquito bite and sharing a meal with PLWHA. Six questions were asked to assess the level of misconceptions on HIV/AIDS. Overall, 14.4% of couples had at least one misconception. Disaggregating the analysis by sex indicated that 14.9% of males and 13.8% of females had at least one misconception. When the composite indicators of knowledge of the three preventive methods and absence of incorrect belief about HIV/AIDS transmission were merged to form a comprehensive indicator of knowledge, comprehensive knowledge was found among 29% of couples (29.7% males &28.2% females). Further analysis of misconceptions was done using the no incorrect beliefs indicator used by United Nations Program on HIV/AIDS (UNAIDS) generated from three common indicators of misconception. Only 49.2% of couples (49.7% of males and 48.7% of females) had no incorrect beliefs. The sex difference in terms of misconception (COR [95%CI] =0.95 [ ]), comprehensive knowledge (COR [95%CI] = 1.34 [ ]) no incorrect beliefs and knowledgeable (COR [95%CI] =1.41 [ ]) was not statistically significant. Knowledge on HIV prevention and transmission had no significant association in HIV sero-discorance in this study (Table 11) HIV Counseling and Testing Overall, 44.1% of male & 30.8% of female respondents had been tested for HIV previously and over 97% had pre and post test counseling. All concordant positives and 11(78.6%) discordant partners had not been tested for HIV previously. There was no statistically significant difference among concordant (97.9%) and discordant (2.1%) partners in previous utilization of VCT (COR [95% CI] = 0.45 [ ]). The commonest reasons mentioned for having VCT in the past 21

28 was to know HIV sero-status, premarital screening and suspicion of infection (Fig.1) Percent Sex of respondents Male Female To have partner To travel abroad Suspicion of infecti Premarital screening Death or illness of Just to know HIV sta Blood donation Reasons for having VCT in the past Fig.1: Reasons mentioned for starting sex among premarital couples in Literates people were 4-times more likely to have VCT previously (AOR [95% CT] =4.80[ ]). Similarly, sexual exposure was significantly associated with having VCT previously (AOR [95% CT] =3.54[ ]). However, gender (AOR [95% CT] =0.70[ ]), knowledge about HIV/ AIDS (AOR [95% CT] =1.04[ ]), and self perception of susceptibility (AOR [95% CT] =0.55[ ]) were not predictors of past VCT utilization. All concordant positives said they would not live together and strengthen sexual relations if tested positive while fiancé tested negative. However, 8 (57.1%) of the discordant couples agreed to live together and strengthen sexual relationship if tested positive while partner tested negative. 22

29 Discordant partners were 22 times as likely to say they would live together and strengthen sexual relations if tested positive while fiancé tested negative than concordant partners (COR [95% CI] = [ ]). Among all the respondents, 116 (29.7%) preferred integrated HIV CT while 244 (62.6%) favored a self standing VCT center. And the rest 7.7% said I don t know (Fig.2) Number Scheme of testing Integrated 40 Male Female Self standing Sex of respondents Fig. 2: VCT Scheme of testing preferred in premarital couples in Bahir Dar, Ethiopia, : Sexual behavior Abstinence from sex before marriage and delay of sexual debut are important strategies that help to reduce the spread of HIV. Interviewees were asked if they had ever had sexual intercourse in the past and 205 (52.6%) were found to have had sexual experience. Disaggregated by sex, a greater proportion of males (59.5%) were sexually active than females (45.6%). Of these 40 (34.2%) males & 23 (11.8%) females were never married (an overall premarital sex rate of 63/244 [25.8%]). Eighty percent of HIV sero-positive individuals had a history of sexual exposure. Of all discordant partners 10(71.4%) claimed ever having sex while 7 (87.5%) of 23

30 concordant positive claim so. There were statistically significant gender differences in premarital sexual activities. Males were two times more likely to engage in premarital sex among nevermarried couples (COR [95%CI] =2.35[ ]). The most common reasons mentioned for starting sex among study couples were marriage 115 (56.1%), personal desire, 63 (30.7%) and peer pressure 13 (6.3%). Among never married couples reasons given were personal desire (60.3%) and peer influence (14.3%) (Table 3) Table 4: Comparison of sexual behavior between male and female study couples in Bahir Dar, Ethiopia, 2008 Variable Female Male X 2 p-value Age at sexual debut* >=18 (n=112) 30(26.8) 82(73.2) <18 (n=59) 42(71.2) 17(28.8) Condom use at first sex No (n=179) 83 (46.4) 96 (53.6) Yes (n=25) 6 (24.0)) 19 (76.0) No. of sexual partner in the past one year One (n= 22) 6 (27.3) 16 (72.7) More than one (n= 9) 1 (11.1) 8 (88.9) Ever use of condom Consistent use (n=11) 4 (36.4) 7 (63.6) Inconsistent use (n 5 (23.8) 16 (76.2) =21) Did not use (n= 60) 24 (40.0) 36 (60.0) * Those who said don t know and no response was removed, since the proportion was low Gender stratified multivariate analysis among study participants showed that females were more likely to initiate sex before the age of 18 than males (x 2 [p value] = [<0.001]). Similarly, there was gender difference in use of condom at first sex (x 2 [p value] = 4.46 [<0.05]). However; 24

31 there was no significant difference in having multiple sexual partner and consistent condom use for the past one year in both sexes (Table 4). In bivariate analysis it was found that people who were literate were more likely to engage in premarital sex (COR [95%CI] =3.53[ ]). Knowledge on HIV was associated with higher risk of premarital sexual engagement (COR [95%CI] = 3.12[ ]). Multivariate analysis showed that, although reverse causality is highly likely, females were half as likely to engage in premarital sex (AOR [95% CI] = 0.49 [ ]). Similarly, those couples those who perceived themselves to be at low or moderate risk of HIV (AOR [95% CI] = 4.24[ ) & 11.72( ]) and those who had had VCT (AOR [95% CI] = 4.67[ ]) previously were more likely to have premarital sex than their counter parts (Table 5) Table 5: Multivariate logistic regression indicating factors association with premarital sex among never married couples in Bahir Dar, Ethiopia, 2008 Variable Premarital sex COR AOR (95% CI) Yes No (95% CI) Sex Female 23 (18.1) 104(81.9) 0.43 ( ) 0.49 ( ) Male 40 (34.2) 77 (65.8) 1.00 Literacy level Illiterate 6 (10.9) 49 (89.1) Literate 57 (30.2) 132(69.8) 3.53( ) 1.08( ) Self perception of chance of exposure to HIV No chance 11(10.5) 94(89.5) Low chance 36(34.0) 70(66.0) 4.40( ) 4.24( ) Moderate chance 12(63.2) 7(36.8) 14.65( ) 11.72( ) Has comprehensive knowledge on HIV transmission 25

32 No 25(16.9) 123(83.1) 0.31( ) 2.02( ) Yes 38(39.6) 58(60.4) Knowledge on HIV prevention No 11(13.3) 72(86.7) 0.32( ) 1.18( ) Yes 52(32.3) 109(67.7) Ever had HIV test No 21(13.9) 130(86.1) Yes 42(45.2) 51(54.8) 5.10( ) 4.67( ) The mean (SD) and median age of first sex was and 18 years respectively. The median age of sexual debut was decreasing across age cohorts from 18 years for current age to 16 years for current age The median age at first sexual intercourse has decreased over the past two decades, from 20 years for men age to 16 years for men age The mean age at first sex among females ( ) was lower than males ( ). While the median age at first intercourse across the different age cohorts in women indicates that there has been a significant change from19 in age to 15.5 for age and to 16.5 for age To investigate the impact of socio-economic variables on age of first sexual debut, multivariate analysis was done. Only gender remained independently associated with age of sexual debut. In this analysis females were 7 times more likely to have engaged in first sexual intercourse before the age of 18 (AOR [95% CI] = 7.90[ ]). However, literacy level, marital status and knowledge on HIV had no effect on age of sexual debut (Table 6). 26

33 Table 6: Association between socio-demographic variables with age of first sexual debut, Bahir Dar, Ethiopia, 2008 Variable Age at first sex* COR (95% CI) AOR(95% CI) <18 >=18 Sex Male 17(17.2) 82(82.8) Female 42(58.3) 30(41.7) 6.75( ) 7.90( ) Literacy level Illiterate 35(50.7) 34(49.3) Literate 24(23.5) 78(76.5) 0.30( ) 0.54( ) Marital status Never married 12(21.4) 44(78.6) Ever married 43(41.3) 61(58.7) 2.59( ) 1.25( ) Living together 4(36.4) 7(63.6) 2.10( ) 1.11( ) Knowledge on HIV prevention No 39(45.3) 47(54.7) 2.70( ) 0.63( ) Yes 20(23.5) 65(76.5) Attitudes on premarital sex Unfavorable 48(35.0) 89(65.0) Favorable 5(17.9) 23(82.1) 1.03( ) 0.40 ( ) * Those who said don t know and no response was removed, since the proportion was The study subjects were asked about their type of first sexual partners, and 55.6% (114) and 39% (80) of them responded married partner and partners not living together respectively. Only 1 (0.7%) male among those ever married had sex with CSW or casual partner, while none of females had sex with casual partner. On other hand among four who had never married,1 male and 1 female had had sex with a casual partner (Fig. 3). Reducing multiple sexual partnerships had a powerful impact on the prevention of HIV infection. Of all couples (7.9%) and of sexually 27