Multi-Country Evaluation of Social Marketing Programs for Promoting HIV Voluntary Counseling and Testing

Transcription

1 Multi-Country Evaluation of Social Marketing Programs for Promoting HIV Voluntary Counseling and Testing Dvora Joseph Kerry Richter Summer Rosenstock Shannon England PSI Research & Metrics Department Working Paper No. 78 December, 2008

2 Population Services International PSI is a Washington, DC-based nonprofit organization that harnesses the vitality of the private sector to address the health problems of low-income and vulnerable populations in more than 60 developing countries. PSI has programs in malaria, reproductive health, child survival, and HIV/AIDS, and deploys commercial marketing strategies to promote products, services and healthy behaviors that enable people to lead healthier lives. PSI is the leading nonprofit social marketing organization in the world. Research & Metrics Population Services International 1120 Nineteenth Street NW, Suite 600 Washington, D.C Authors Dvora Joseph: Population Services International/Mozambique Kerry Richter: Institute for Population and Social Research, Mahidol University, Thailand Summer Rosenstock: Population Services International Shannon England: Population Services International Recommended Citation Joseph, D., Richter, K., Rosenstock, S. & England, S. (2008). Multi-country evaluation of social marketing programs for promoting HIV voluntary counseling and testing. (Working Paper No. 78). Washington, DC. Population Services International. Acknowledgments The authors would like to thank all donors of the VCT programs in Kenya, Namibia and Zimbabwe including USAID, CDC, PEPFAR, and DFID; and the Ministries of Health in Kenya, Namibia and Zimbawe; the PSI country platforms and staff for their assistance with data collection and analysis; and the PSI research staff who reviewed and edited this paper

3 ABSTRACT Population Services International (PSI) implements HIV voluntary counseling and testing (VCT) programs in over twenty-five countries in Africa, Asia, Latin American and the Caribbean. Three of these programs in East and Southern Africa are examined by analyzing multi-round surveys of sexually active men and women This paper investigates the determinants of VCT seeking behavior, changes in these determinants over time, and the impact of VCT social marketing campaigns on HIV testing seeking behavior and its determinants. The maturity of a VCT program in a country appears to play an important role in the motivation for HIV testing, with those in countries with more recent access to VCT being motivated by knowledge of HIV and its threat to personal health. For mature VCT programs (existing for more than 3 years), and once latent demand has been met, more intransigent barriers to testing become important, including self-efficacy for HIV testing, stigma, and outcome expectations. For youth, interpersonal communications and social support from peers emerged as important factors. The proportion of target populations who were tested increased in two of three countries examined when controlling for other factors. Key determinants of receiving HIV testing also changed, but there was no clear pattern in these trends by country. Finally, an examination of whether exposure to VCT social marketing campaigns affected HIV testing and its determinants showed a significant association in three countries. The results indicate that social marketing can have a positive impact on the demand and uptake of HIV testing as well as its behavioral determinants. Targeting communication messages at the behavioral determinants that will most influence motivation is essential for increasing the use of VCT services among target populations who are least likely to test. The findings indicate that a variety of communication approaches can be effective, and that modifying campaigns as the program matures and the population awareness around HIV testing benefits is essential. Despite increased access to treatment and prevention services, a large proportion of people in generalized epidemics still do not know their HIV status. Social marketing of VCT is a powerful tool that should be used to continue to expand demand for VCT services in high HIV prevalence countries

4 INTRODUCTION HIV voluntary counseling and testing is an important component of public health efforts to reduce HIV incidence and increase access to care, treatment and support. Several studies indicate that client-initiated voluntary counseling and testing (VCT) can help reduce risky sexual behaviors, especially among HIV-discordant couples and individuals who test HIV-positive (Glick, 2005; Weinhardt et. al., 1999). There is evidence that individuals who know their HIV status are more likely to take measures to remain uninfected or to access antiretroviral therapy (ART) and other palliative services to prolong their lives and avoid infecting others (The Voluntary HIV-1 Counseling and Testing Efficacy Study Group, 2000). Those who undergo VCT and test HIV-negative are able to sustain or change their behaviors to maintain their negative status; those who test HIV-positive and receive counseling are able to change their behaviors to protect themselves as well as their spouses, other partners and future offspring. VCT has been shown to be a very cost-effective prevention intervention, with an estimated cost of about $13 to $18 per disability-adjusted life year (DALY) saved and $240 to $346 per HIV infection averted (Sweat et. al., 2000). International research indicates that although VCT has become more widely available, promotions and marketing campaigns are still needed to encourage testing. A 2006 study showed that the most common barriers to seeking testing are psychological in nature, including anxiety over possible results and fear of stigma (Sherr, 2006). A study in Zimbabwe showed that while uptake of HIV testing increased over time from 6% to 11%, the motivation to seek VCT was driven by knowledge and education rather than sexual risk-taking behavior. (Sherr et. al., 2007). In another study of VCTseeking behavior in Tanzania, there were higher rates of HIV testing among women whose spouses had completed VCT than those whose spouses had not an indication that the promotion of couples counseling may increase uptake among married women (Isingo, 2006). Population Services International (PSI) provides VCT services in more than 25 countries throughout the developing world, and implements multi-round cross-sectional surveys to inform VCT program development, monitor progress and evaluate program effectiveness. The survey data enable PSI to investigate whether possible determinants of deciding to get tested for HIV are consistent across countries and how these predictors change as programs mature

5 This paper analyzes two rounds of survey data from three sub-saharan African countries: Kenya, Namibia and Zimbabwe. The paper has three specific aims: 1. Identify possible determinants of a person s decision to get tested for HIV; 2. Assess whether the proportion of people getting tested for HIV and/or the determinants associated with testing changed over time; and 3. Examine whether HIV testing behavior and associated determinants appear to be related to exposure to VCT social marketing. VCT PROGRAMS IN KENYA, NAMIBIA AND ZIMBABWE Kenya, Namibia and Zimbabwe were chosen as focus countries for this study because of their longstanding VCT social marketing interventions and the availability of baseline and follow-up data. They provide a diverse sampling of PSI s VCT programs. The Zimbabwe program, launched in 1999, is PSI s oldest and largest VCT program, while the Namibia program is one of the newest, and PSI/Kenya only implemented social marketing campaigns promoting VCT without direct service delivery (provided by other NGOs and the public health sector). The study also offers the opportunity to compare PSI-branded facilities (New Start in Zimbabwe and Namibia) with those that are run in partnership with a government (Kenya) and are promoted with generic branding. VCT Social Marketing in Kenya In 2000, the Government of Kenya began working with key donors (including the World Bank and the US Government) and implementing organizations to rapidly scale up VCT within health facilities and within NGOs who established stand-alone VCT centers. Within five years, the number of registered VCT sites increased from three to 585. The national plan included a multistage promotional campaign to support the scale-up of VCT services and to increase public demand for these services. PSI developed a simple, easily recognizable logo for use in that campaign, and radio, TV, and print materials that targeted different groups (youth, couples, heads of households) with aspirational messages and celebrity appeals. Logo signboards were also provided to registered VCT sites, which were required to meet quality assurance standards or else face the prospect of logo removal and deregistration. PSI developed and evaluated four mass media campaigns have promoted VCT in Kenya through various media channels: radio advertisements, radio show discussions, press advertisements, posters, - 3 -

6 flyers, billboards and advertising on street signs. The first campaign built confidence in VCT services by asking common questions about HIV and inviting the audience to discuss this question at a VCT center near you. In 2002 and 2003, a campaign called Chanuka called on young people to learn their HIV status in order to get in control of their life. This was followed by Chanukeni Pamoja, which sought to make it a norm for young couples to learn each other s HIV status when planning for key events such as marriage. After ART became available at provincial hospitals, the fourth VCT campaign emphasized the message that while most people test HIV negative, there is hope and treatment available for people who test HIV positive. New Start/Namibia Social Marketing Association (SMA) Namibia, PSI s Namibian affiliate, created and oversaw New Start/Namibia network since Intrahealth Namibia took over the network of VCT sites in SMA provided operating procedures, training, supervision, marketing and data management. Some of the network s 17 sites are managed by non-governmental organizations (NGOs) and faithbased organizations. Some sites are freestanding facilities while others are integrated into larger health programs, including those at mission hospitals. Most are urban or peri-urban facilities. The MOH recently allowed the expansion of mobile VCT to rural areas (in 2007). Namibia also only allowed rapid HIV testing in 2006 which increased access to rapid HIV test results. New Start/Namibia has been publicized extensively through radio broadcasts aimed at urban youth. The youth-focused Know for Sure campaign used radio and billboards to promote HIV testing. The Knowledge is Power campaign promoted VCT to soldiers as part of the Military AIDS Prevention Program to increase access to VCT and prevent HIV among the military. Additionally, a song contest was held to destigmatize HIV testing. New Start/Zimbabwe When PSI created the New Start VCT brand in 1999, its goal was to use commercial marketing techniques to improve demand for and access to high-quality VCT services. PSI worked in partnership with Zimbabwe s Ministry of Health and Child Welfare to steadily expand the program, and by December 2007, New Start centers in Zimbabwe had served more than 1 million clients an estimated 17% of the sexually active population. As of December 2008, the New Start/Zimbabwe network included 20 VCT centers throughout the country. Of these, five were operated by PSI and - 4 -

7 15 were operated by partner organizations: seven by NGOs, five by the government, two by private companies and one by the University of Zimbabwe. Some sites are located within public health care facilities where they recently began offering provider initiated testing and counseling (PITC) services to in-patient and out-patient clients as part of a national pilot PITC service delivery model. New Start/Zimbabwe communication strategies have utilized TV, radio and print media, as well as interpersonal communications such as peer education. In 2000, the first major promotional campaign, Make a New Start Today, emphasized hope and peace of mind as key benefits of learning one s HIV status and practicing safe sexual behaviors. The second campaign, Let s Talk, stressed that counseling was confidential and affordable. This was followed by Get Real, which encouraged young people on the verge of major life commitments such as marriage to realistically assess personal risks and take control of their future by learning their HIV status. The 2006 Get Real Early campaign focused on the potential for VCT services to facilitate access to early and effective treatment for those who test HIV-positive. METHODOLOGY Theoretical Framework The design for this study was guided by the PSI Behavior Change Framework (Figure 1), which includes behavioral determinants which are theorized to influence whether an individual utilizes a product, service, or risk-reducing behavior. Figure 1: The PSI Behavior Change Framework - 5 -

8 The PSI Behavior Change Framework categorizes behavioral determinants into 16 summary constructs, which are classified as either opportunity, ability, or motivation determinants. Opportunity determinants encompass institutional or structural factors that influence an individual s chance of performing a desired behavior. Ability determinants relate to an individual s skill or proficiencies needed to perform a promoted behavior. Motivation determinants include factors associated with an individual s desire to perform the behavior in question. This study prioritized the investigation of eight determinants thought to be particularly relevant to HIV testing behavior in the three study populations: social norms, knowledge, attitudes, social support, threat, self-efficacy, beliefs and outcome expectations. Sample and Design Two rounds of data for each country were used in this analysis. All were general population surveys targeting men and women aged Only respondents who had been sexually active in the last 12 months were included in the analyses since sexual activity was considered the primary risk factor for HIV infection. Kenya s first and second round surveys were administered to randomly selected individuals in randomly selected households in Kenya s 13 largest towns and cities. The survey was orally administered in one of Kenya s nine primary languages, as appropriate. Kenya s first round survey was conducted in 2004 had a total sample size of 1,416, and the second round survey was conducted in 2005 had a total of 1,546. Namibia s first and second round surveys were administered to randomly selected households in five priority locations targeted by the VCT campaign. Experienced field staff contacted households and selected a member within the age range; surveys were conducted orally by same-sex staff and the answers were transcribed. Namibia s first round survey was conducted in 2002 had a total sample size of 1,499, and the second round survey was conducted in 2005 had a total sample size of 1,499. Zimbabwe s study sample was selected in two stages. In the first stage, enumeration areas (EAs) were randomly selected using probability proportionate to size. In the second stage, households within the selected EAs were selected using simple random sampling. In households where more than one eligible respondent was available, a respondent was randomly selected using the Kish grid method. Surveys were administered orally. Zimbabwe s first round survey was conducted in

9 had a total sample size of 2,230, and the second round survey was conducted in 2006 had a total sample size of 958. The second round sample size is much smaller because it targeted a larger age range; in order to make the data sets comparable, respondents who were above 35 years in age were excluded from the sample. Measures Demographics For each of the three countries, the survey included questions on socio-demographic characteristics including age, gender, marital status, place of residence (rural vs. urban), socioeconomic status, and education level. Behavioral Determinants Each of the three countries measured similar opportunity, availability, and motivation variables; this section only details the measures for those determinants that were shown to be significant in multivariate analysis, for the sake of brevity. Kenya. Behavioral determinants presented in this paper include the ability-related determinants of knowledge, social support, and self-efficacy; no opportunity or motivation variables were significant. Knowledge of where to get tested for HIV was measured using free response; as knowledge of one place for testing was nearly universal, those who could list two or more places were considered as knowing somewhere to get tested. Knowledge of mother-to-child transmission (MTCT) of HIV was measured with an index of four true or false questions; incorrect answers were coded as 0 and correct answers were coded as 1, with a possible range of 0-4. Social support for discussing HIV-related topics was measured as a yes/no response to the question, In the past three months, have you talked one-to-one with a peer educator or health worker about HIV or AIDS?. No was coded as 0 and yes as 1. Self-efficacy for using condoms and abstaining from sex was measured using a scale of 13 questions asking about the likeliness of using condoms or abstaining. Reliability testing showed a Cronbach s alpha of.67 for the scale. Each item was measured using a Likert scale of 1-4, with 1 being totally - 7 -

10 disagree and 4 being totally agree; scores were averaged across the questions to produce a score for each individual, with a range of 1-4. Namibia. Behavioral determinants presented in this paper include the opportunity-related determinant of social norms, the ability-related determinant of knowledge, and the motivationrelated determinants of attitudes, beliefs, and threat. Social norms was defined as knowing others who have been tested for HIV, and was measured as a yes/no response to the question, Do you know of anyone who has taken an AIDS virus, HIV, test? No was coded as 0 and yes as 1. Knowledge of where to get tested for HIV was measured as a yes/no response to the question, Do you know anyplace in or near this community where a person can go to get a test for the AIDS virus, HIV? No or not sure was coded as 0 and think so or yes was coded as 1. The attitude that one would purchase products from a person with HIV was measured by asking respondents to indicate their level of agreement with the statement, If a shopkeeper had the AIDS virus, HIV, I would still buy products from them, including fresh produce. The choice of answers was provided on a Likert scale of 1-5, with 1 being strongly disagree and 5 being strongly agree. Attitudes about not getting tested were measured by having participants list up to three reasons why they might hesitate to get an HIV test; those who cited no reasons were coded as 0 and those who listed 1 or more were coded as 1. Belief that HIV tests are reliable was measured by asking participants if they felt that a positive result on an HIV test was reliable. The choice of answers was provided on a Likert scale of 1-5, with 1 being strongly disagree and 5 being strongly agree. Risk perception in the community was measured by asking participants level of agreement with the statement, Knowing one s own AIDS status doesn t matter, because it is really not a problem here. The choice of answers was provided on a Likert scale of 1-5, with 1 being strongly agree and 5 being strongly disagree. Personal risk perception of being infected with HIV was measured by asking participants if they considered themselves to be at no (coded as 0), low (coded as 1), don t know (coded as 2), moderate (coded as 3), or high risk of acquiring HIV (coded as 4)

11 Knowing someone who has died of AIDS was measured as a yes/no response to Do you personally have an acquaintance, friend, family member or relative that you suspect or know is sick with AIDS or who has died of AIDS? ; no was coded as 0 and yes was coded as 1. Zimbabwe. Behavioral determinants presented in this paper include the ability-related determinants of knowledge and self-efficacy and the motivation-related determinants of attitudes and outcome expectation; no opportunity variables were significant. Knowledge of MTCT of HIV was measured using an index of five yes/no questions about MTCT; incorrect answers were coded as 0 and correct answers were coded as 1, with a possible score range of 0-5. Self perceived ability (self-efficacy) to use VCT services was measured by asking participants level of agreement with the statements I am capable of going for counseling and testing on my own and I can talk to my partner about HIV counseling and testing, using a Likert scale of 1-5, with 1 being strongly disagree and 5 being strongly agree. Attitudes regarding stigma were measured using an 11 question scale that included items about various activities that could potentially transmit HIV from an infected person to a non-infected person; reliability analysis for the scale was conducted, with a Cronbach s alpha of.86. Each question was measured on a Likert scale of 1-5, with 1 being strongly disagree and 5 being strongly agree; a mean was derived for each individual by averaging across all the questions. Enacted stigma was measured using a 13-item index of negative outcomes for persons living with HIV; participants indicated whether any of these happened in their community, with no being coded as 0 and yes as 1, for a possible range of Outcome expectations for VCT was measured using a scale of nine items asking about whether VCT was a prerequisite for various outcomes; the scale had a Cronbach s alpha of Each question was measured on a Likert scale of 1-5, with 1 being strongly disagree and 5 being strongly agree; a mean was derived for each individual by averaging across all the questions. Exposure For each country, a composite variable was created to capture exposure to the social marketing campaign. This variable included the number of messages received and the number of channels - 9 -

12 through which those messages were received. In all of the countries, baseline exposure and no exposure at endline were considered the same. In Kenya, low exposure included those exposed to one message and no channels reported; one message and one channel reported; and two messages and no channels reported. Medium exposure included those exposed to one message and two channels and to two channels and one message. High exposure included those exposed to two messages through two or more channels. The data from Namibia did not include information on specific messages, but did include information on the number of channels through which messages were received. Low exposure included those exposed to one channel; medium, those exposed to two channels; and high, those exposed to three or more channels. For Zimbabwe, there were a total of nine possible messages and seven possible channels for each message. Low exposure included those who had been exposed to one to four messages with no channels reported; those who had been exposed to one to four messages through one to seven channels; and those who reported being exposed to five to six messages but did not report any channels. Medium exposure included those who had been exposed to one to four messages through eight to 15 channels; those exposed to five to six messages through one to seven channels; and those exposed to five to six messages through eight to 15 channels. High exposure included those exposed to five to six messages through 16 to 28 channels; those exposed to seven to eight messages through eight to 15 channels; and those exposed to seven to eight messages through 16 to 28 channels. Channels in all three countries included radio, TV, billboards, peer education, pamphlets and counseling. Testing Behavior For Kenya, testing was measured using the question Have you ever gotten an HIV test? with a yes/no response. Respondents were also asked if the test was voluntary, and if they had received the results of their most recent test. For Namibia, testing was measured using the question Have you ever been tested for HIV? with a yes/no response. The respondents were also asked if pre- and post-test counseling was provided

13 For Zimbabwe testing was measured using the same question Have you ever been tested for HIV? with a yes/no response. Analysis For each country, data from the two rounds were analyzed. Reliability testing and, as appropriate, factor analysis were used to develop scale variables for surveys that included scaled items. Additionally, principle component analysis was used in Kenya and Zimbabwe to develop a weighted socio-economic status (SES) index based on household possessions; the index was then used to divide the sample into socio-economic quartiles. In Namibia, the only available measure of socioeconomic status was income level. The following analytic steps were used for each of the countries. 1. Identify possible determinants of a person s decision to get tested for HIV. Multivariate analysis using logistic regression was performed to identify predictors significantly associated with HIV testing utilization (defined as being tested for HIV). Though some of the countries included information distinguishing HIV testing from VCT (i.e. receiving counseling with testing), this information was not available for all countries so HIV testing utilization was chosen as the outcome of interest to provide the most comparable results across countries. The most recent survey round in each country was used in order to capture which covariates are currently important in each country and to explore how these covariates differ. The regression models were fitted using the backwards stepwise approach. 2. Assess whether the proportion of people getting tested for HIV and/or the determinants associated with testing changed over time. Adjusted proportions were generated using logistic regression to determine whether there were significant differences in the proportion of respondents who had been tested for HIV over time, comparing baseline with follow-up results for each country. The analyses controlled for all explanatory and control covariates in the final models obtained under the first aim. Additionally, adjusted proportions and means were generated to identify significant changes in explanatory covariates identified in the final models under the first aim, comparing baseline with follow-up results, while controlling for all available sociodemographic variables

14 3. Examine whether HIV testing behavior and associated determinants appear to be related to exposure to VCT social marketing. Associations between VCT social marketing and HIV testing, and between VCT social marketing and determinants of testing, were examined by generating adjusted proportions, stratified by level of exposure to PSI s communications program. The exposure variable was created by combining composite variables for the number of messages received and the number of channels through which messages was received. The categories were: baseline (pre-exposure); no exposure at followup; and low, medium and high exposure at follow-up. Adjusted proportions, stratified by level of exposure to PSI s communications, were generated for those covariates found to be significantly different over time. The appropriate model for each covariate was used, controlling for all available socio-demographic variables. RESULTS Population Characteristics of Baseline and Follow-up Samples Unadjusted population characteristics for the baseline and follow-up groups in Kenya, Namibia and Zimbabwe are presented in Table 1. Kenya. About one-third of Kenyan respondents in both the baseline and follow-up groups were between the ages of 20 and 24, and almost another one-third were between the ages of 25 and 29. Both groups had close to equal representation of males and females. Slightly less than 60% of both baseline and follow-up respondents were married, and slightly more than two-thirds lived in urban areas. Socioeconomic status (SES) changed from baseline to follow-up, with larger proportions of respondents in the follow-up group falling into the lower three income quintiles and smaller proportions falling into the higher two quintiles (p<0.001). Another shift occurred for educational level, with the proportions of respondents in the none/primary and junior/some secondary categories increasing while proportions for those who completed secondary and attended school beyond secondary decreased (p<0.001). Namibia. The age distributions for the Namibian baseline and follow-up groups were similar, with a little more than 20% of both groups between the ages of 15 and 19; about 35% of both groups between the ages of 20 and 24; about 25% of both groups between the ages of 25 and 29; and the

15 remainder between the ages of 30 and 35. There were more female respondents in the baseline group (52.4% vs. 46.5%, p<0.01), as well as more married respondents (22.3% vs. 17.6%, p<0.01). A significant change was also found in SES, with more than half of baseline respondents falling into the upper two quartiles but more than half of follow-up respondents falling into the lower two quartiles (p<0.001). Almost two-thirds of both the baseline and follow-up respondents reported either completing secondary school or receiving further education beyond secondary school. Zimbabwe. A change was seen between the ages of baseline and follow-up respondents, with the proportion of respondents aged increasing at follow-up while the proportions of respondents in other age groups decreased (p<0.001). Almost half of respondents in both groups were female, and about half of respondents in both groups were married. The proportion of urban respondents decreased from 58.8% at baseline to 52.5% at follow-up (p<0.01). SES did not change significantly, but a change was seen in respondents educational levels (p<0.05); the proportion completing secondary school increased from 67.3% at baseline to 71.8% at follow-up, while proportions of people in the other two categories, none/primary and beyond secondary decreased

16 Table 1: Unadjusted population characteristics at baseline and follow-up, Kenya, Namibia and Zimbabwe Kenya Namibia Zimbabwe p-value p-value p-value N=1,416 N=1,546 N=1,171 N=1,160 N=2,230 N=958 Age years 15.1% 14.9% 24.6% 20.2% 13.2% 10.3% years 33.4% 32.8% 34.5% 34.8% 28.7% 20.2% years 29.6% 29.4% 23.6% 26.7% 30.0% 43.2% years 21.9% 22.9% n.s. 17.3% 18.4% n.s. 28.1% 26.3%` *** % Female 48.5% 49.1% n.s. 52.4% 46.5% ** 47.5% 46.2% n.s. % Married 57.7% 59.1% n.s. 22.3% 17.6% ** 52.5% 49.2% n.s. % Urban 67.4% 67.4% n.s. N/A N/A N/A 58.8% 52.5% ** SES Low 20.9% 23.7% 24.0% 30.4% 24.7% 24.6% Medium low 19.8% 23.8% 23.0% 26.0% 15.4% 13.9% Medium 18.9% 20.9% 30.0% 24.2% 21.4% 20.9% Medium high 22.6% 18.3% 22.9% 19.5% 19.6% 22.1% High 17.9% 13.2% *** N/A N/A *** 19.0% 18.5% n.s. Education None/primary 36.3% 51.0% 16.3% 14.0% 19.8% 16.9% Junior/some secondary 5.2% 12.6% 18.9% 21.9% N/A N/A Completed secondary 39.3% 22.6% 58.2% 57.3% 67.3% 71.8% Beyond secondary 19.2% 13.8% *** 6.6% 6.8% n.s. 12.9% 11.3% * OR = odds ratio. Sig. = significance level. *p < **p < ***p < n.s. = not significant. HIV Testing Determinants Adjusted data on associations between HIV testing behavior and socio-demographic indicators are presented in Table 2, and between HIV testing behavior and behavioral indicators, in Table 3. Kenya. In the Kenyan follow-up cohort, people who had been tested for HIV differed from people who had not been tested for HIV in regard to three socio-demographic indicators and four behavioral indicators. The group that reported being tested for HIV had larger proportions of

17 female respondents and married respondents than the group not tested (OR=2.28, p<0.001; OR=1.78, p<0.001). Also, more tested people than untested people reported being educated beyond the secondary school level (OR=1.86, p<0.01). As for behavioral indicators, more respondents who had been tested for HIV reported knowing where to go for HIV testing than did their counterparts (OR=1.81, p<0.001). The mean score for knowledge of mother-to-child-transmission of HIV (MTCT) was higher for the group that had been tested (OR=1.12, p<0.05). Furthermore, the proportion of respondents who reported having discussions about sex, condom use and/or HIV in the previous three months was larger for the tested group (OR=2.40, p<0.001), and that group also scored higher on a self-efficacy scale assessing self-perceived ability to use condoms and abstain from sex (OR=1.54, p<0.01). Namibia. Namibians who had been tested for HIV were found to differ significantly from those not tested on three socio-demographic indicators and eight behavioral indicators. There were significant differences in HIV testing behavior for different age brackets and different SES levels, with larger proportions of tested versus not tested people in the older age brackets and higher SES quartiles. Also, the group tested for HIV included a larger proportion of women than the group not tested (OR=3.15, p<0.001). Regarding behavioral indicators, respondents who had been tested were more likely to know others who had been tested for HIV (OR=2.03, p<0.001) and to know where to get tested for HIV (OR=1.89, p<0.05), while also being less likely to cite reasons for not getting tested for HIV (OR=0.37, p<0.001). They reported a greater willingness to buy products from an HIV-positive shopkeeper (OR=1.15, p<0.05). Also, a greater proportion of people who had been tested reported knowing someone who has died of AIDS (OR=1.72, p<0.001). However, that group scored lower than the group not tested for HIV on indices measuring respondents perceptions of HIV risk in the community and of personal HIV risk (OR=0.88, p<0.05; OR=0.83, p<0.01). A third association in the unexpected direction was found: respondents who had been tested scored lower than their counterparts on an index measuring the belief that HIV tests are reliable (OR=0.86, p<0.01). Zimbabwe. In Zimbabwe, the group tested for HIV and the group not tested for HIV differed significantly on three socio-demographic indicators and five behavioral indicators. The tested group included a higher proportion of females (OR=1.49, p<0.05), a higher proportion of people in the medium socioeconomic quintile (OR=1.90, p<0.05) and a higher proportion of people with

18 beyond secondary education (OR=2.19, p<0.05). The tested group had higher mean scores on an index measuring knowledge of MTCT (OR=1.24, p<0.01) and a scale measuring self-perceived ability to utilize VCT services (OR=1.87, p<0.001). The tested group also scored higher on a stigma scale (OR=1.40, p<0.05) and an enacted stigma index (OR=1.06, p<0.05). However, the tested group scored lower on a scale measuring VCT outcome expectations (OR=0.65, p<0.01)

19 Table 2: Socio-demographic determinants of HIV testing in follow-up cohorts in Kenya, Namibia and Zimbabwe (adjusted) Kenya 2005 Namibia 2005 Zimbabwe 2006 Tested for HIV OR Sig. Tested for HIV OR Sig. Tested for HIV Yes N=508 No N=869 Yes N=508 No N=869 Yes N=508 No N=869 Age years 9.0% 9.9% Ref Ref 7.9% 21.1% Ref Ref 2.6% 5.4% Ref Ref years 33.5% 31.5% 1.14 n.s. 32.6% 33.9% 2.40 *** 18.9% 18.1% 1.85 n.s years 28.6% 29.3% 1.06 n.s. 32.8% 22.7% 3.72 *** 43.7% 41.6% 1.94 n.s years 17.1% 17.6% 1.06 n.s. 19.5% 13.5% 3.87 *** 25.5% 24.8% 1.97 n.s. Sex (% Female) 60.1% 39.9% 2.28 *** 64.8% 37.2% 3.15 *** 52.9% 43.0% 1.49 * Marital Status 68.0% 54.8% 1.78 *** 13.0% 12.3% n.s. 51.1% 46.1% 1.26 n.s. (% married) Residence (% urban) 72.0% 68.8% 1.17 n.s. N/A N/A N/A N/A 48.4% 47.1% 1.00 n.s. Socioeconomic Status Low 16.8% 19.4% Ref Ref 16.3% 31.5% Ref Ref 7.2% 10.7% Ref Ref Medium Low 22.6% 22.9% 1.14 n.s. 26.2% 23.4% 2.14 *** 12.5% 9.9% 1.74 n.s. Medium 19.7% 20.4% 1.15 n.s. 25.0% 21.7% 2.38 *** 23.6% 19.1% 1.90 * Medium High 17.4% 16.6% 1.24 n.s. 23.7% 14.1% 3.44 *** 17.5% 18.9% 1.50 n.s. High 9.4% 7.0% 1.57 n.s. N/A N/A N/A N/A 9.3% 10.1% 1.36 n.s. Education None/Primary 46.7% 52.8% Ref Ref 7.0% 8.8% Ref Ref 8.5% 13.8% Ref Ref Junior secondary/ 10.4 % 11.9% 1.03 n.s. 22.6% 19.5% 1.56 n.s. N/A N/A N/A N/A some secondary Secondary 20.5% 19.9% 1.27 n.s. 58.4% 57.4% 1.29 n.s. 74.7% 71.6% 1.62 n.s. Beyond Secondary 9.9% 6.6% 1.86 ** 3.7% 4.0% 1.41 n.s. 6.2% 4.5% 2.19 * OR Sig. Notes Pseudo R 2 = for regression model consisting of all significant items. Pseudo R 2 = for regression model consisting of all significant items. Pseudo R 2 = for regression model consisting of all significant items. LR Chi 2 = , df = 17, p< LR Chi 2 = , df = 20, p< LR Chi 2 = , df = 17, p< OR = odds ratio. Sig. = significance level. *p < **p < ***p < n.s. = not significant

20 Table 3: Behavior-related predictors of HIV testing in follow-up cohorts in Kenya, Namibia and Zimbabwe, categorized as opportunity, ability and motivation (adjusted) Kenya 2005 Namibia 2005 Zimbabwe 2006 Tested for HIV OR Sig. Tested for HIV OR Sig. Tested for HIV OR Yes N=508 No N=869 Yes N=354 No N=781 Yes N=254 No N=627 OPPORTUNITY Social Norm Know others who have been tested for HIV *** ABILITY Knowledge Know where to get tested for HIV 42.0% 28.6% 1.81 *** * Knowledge of mother-tochild-transmission of HIV * ** Social Support Discussed sex, condom use and/or HIV in the last three 27.0% 13.4% 2.40 *** months Self-Efficacy Self perceived ability to use condoms and abstain from sex ** Self perceived ability to use VCT services *** MOTIVATION Attitudes Would buy products from an HIV-positive shopkeeper * One or more reasons cited for not getting tested *** Stigma * Enacted stigma * Belief Believe HIV tests are reliable ** Outcome Expectation voluntary counseling and testing outcome expectation ** Threat Risk perception in the community * Personal risk perception ** Know someone who has died of AIDS *** Notes Pseudo R 2 = for regression model consisting of all significant items. LR Chi 2 = , df = 17, p< Pseudo R 2 = for regression model consisting of all significant items. LR Chi 2 = , df = 20, p< Pseudo R 2 = for regression model consisting of all significant items. LR Chi 2 = , df = 17, p< OR = odds ratio. Sig. = significance level. *p < **p < ***p < n.s. = not significant Sig.

21 Changes in HIV Testing and in Behavioral Determinants of HIV Testing Over Time Baseline and follow-up indicators were compared to identify significant changes in HIV testing behavior and in behavioral determinants in the three countries (Table 4). Both Namibia and Zimbabwe had significantly higher proportions of follow-up respondents reporting that they had been tested for HIV (22.3% baseline vs. 26.9% follow-up, p<0.05, and 19.4% baseline vs. 29.6% follow-up, p<0.001, respectively). The data from Kenya did not show a significant change, with 34.6% of baseline respondents and 36.3% follow-up respondents reporting that they had been tested. A significant change occurred in at least one ability-related indicator for each of the three countries, although one of the changes was negative. The Kenyan follow-up group scored higher than the Kenyan baseline group on measures of knowledge of MTCT (2.76 baseline vs follow-up, p<0.001) and self-perceived ability to use condoms and abstain from sex (2.84 baseline vs follow-up, p<0.001). A higher proportion of people in the Namibian follow-up group than the Namibian baseline group reported knowing where to get tested for HIV (81.4% baseline vs. 89.4% follow-up, p<0.001). The negative change occurred for Zimbabwe; that baseline group scored higher than the follow-up group on a scale measuring self-perceived ability to use VCT services (4.06 baseline vs follow-up, p<0.001). Significant changes in motivation-related indicators only occurred in Namibia, and only one of those changes was positive. The Namibian follow-up group scored higher than the Namibian baseline group on a measure of willingness to buy products from an HIV-positive shopkeeper (3.27 baseline vs follow-up, p<0.001). However, the follow-up group scored lower on two other indicators: one measuring the belief that HIV tests are reliable (3.76 baseline vs follow-up, p<0.001), and one measuring HIV risk perception in the community (4.05 baseline vs follow-up, p<0.001) Also, a smaller proportion of the follow-up group reported knowing someone who had died of AIDS (65.2% baseline vs. 56.8% follow-up, p<0.001)

22 Table 4: Changes over time in behavior and in opportunity/ability/motivation-related determinants, Kenya, Namibia and Zimbabwe INDICATORS Country Baseline Follow-up Sig. BEHAVIOR Tested for HIV and received results Kenya 34.6% 36.3% n.s. Namibia 22.3% 26.9% * Zimbabwe 19.4% 29.6% *** OPPORTUNITY Social Norm Know others who have been tested for HIV Namibia 49.9% 50.8% n.s. ABILITY Knowledge Know where to get tested for HIV Kenya 34.4% 33.7% n.s. Namibia 81.4% 89.4% *** Knowledge of MTCT Kenya *** Social Support Discussed sex, condom use and/or HIV in the last three months Kenya 21.0% 19.6% n.s. Self-Efficacy Self-perceived ability to use condoms and abstain from sex Kenya *** Self-perceived ability to use VCT services Zimbabwe *** MOTIVATION Attitudes Would buy products from HIV+ shop keeper Namibia *** 1 or more reasons cited for not getting tested Namibia 27.7% 29.5% n.s. Belief Believe HIV tests are reliable Namibia *** Threat Risk perception in the community Namibia *** Personal risk perception Namibia n.s. Know someone who has died of AIDS Namibia 65.2% 56.8% *** Sig. = significance level. *p < **p < ***p < n.s. = not significant. Associations with Exposure to VCT Social Marketing For indicators that changed significantly between baseline and follow-up (Table 4), UNIANOVA was performed to determine whether or not these changes were associated with exposure to the VCT social marketing intervention. Comparisons of differences in behavior and behavioral determinants were made between the baseline group and those in the follow-up group who reported no exposure to the intervention, low exposure, medium exposure, or high exposure (Table 5)

23 Zimbabwe was the only country that exhibited a statistically significant relationship between exposure to a VCT campaign and HIV testing behavior (p<.001). The baseline group had a lower percentage of respondents who were tested for HIV and received their results at baseline in comparison with the medium and high exposure groups at follow-up (19.5% vs. 31.1%, p<.001, and 19.5% vs. 31.7%, p<.001, respectively). None of the four follow-up groups (no, low, medium, and high exposure) differed significantly from one another. Associations were found between exposure and all of the ability-related behavioral determinants that had changed significantly from baseline to follow-up. For Namibia, the knowledge item know where to get tested for HIV demonstrated a statistically significant relationship with exposure to VCT campaigns (p<.001). The percentage of respondents in the baseline group who knew where to get tested was significantly higher than the no exposure follow-up group (81.5% vs. 53.5%, p<.001), and significantly lower than the low, medium, and high exposure follow-up groups (81.5% vs. 100%, p<.001, for all three). The no exposure follow-up group was also significantly lower than the low, medium, and high exposure follow-up groups (53.5% vs. 100%, p<.001, for all three) indicating that campaigns improved knowledge of testing locations. For Kenya, the index for knowledge of MTCT was significantly different across exposure groups (p<.001), with the low, medium, and high exposure follow-up group respondents having a higher mean knowledge than the baseline (2.76 vs. 2.98, p<.01; 2.76 vs. 3.00, p=.074; 2.76 vs. 3.01, p<.001, respectively) and the no exposure follow-up group (2.62 vs. 2.98, p<.05; 2.62 vs. 3.00, p=.224; 2.62 vs. 3.01, p=1.31, respectively). Exposure was related to measures of self-efficacy for both Kenya and Zimbabwe. In Kenya, the self perceived ability to use condoms and abstain from sex was significantly related to exposure (p<.001), with the baseline (2.84), no exposure follow-up (2.83), and low exposure follow-up (2.89) scoring lower on the self-efficacy scale than those in the medium and high exposure follow-up groups (2.84 vs. 2.99, p<.001; 2.84 vs. 2.99, p<.001; 2.83 vs. 2.99, p<.01; 2.83 vs. 2.99, p<.001; 2.89 vs. 2.99, p<.05; 2.89 vs. 2.99, p<.01). For Zimbabwe, there were mixed results in the relationship between exposure and self-efficacy to use VCT services (p<.001). At baseline, respondents scores were significantly higher than the exposed follow-up groups (4.06 vs p<.001 [low]; 4.06 vs. 3.60, p<.001 [medium]; 4.06 vs. 3.63,

24 p<.001 [high]. None of the exposed follow-up groups differed significantly from one another, but the low exposure group was significantly lower than the no exposure group (3.48 vs. 3.83, p<.05). For Namibia, motivation-related determinants showed a relationship between exposure and four indicators of attitudes, beliefs, and threat. For the attitude measure, would buy products from an HIV-positive shop keeper, scores increased significantly between baseline and all four follow-up groups (3.27 vs. 4.04, p<.001 [no exposure]; 3.27 vs. 3.95, p<.001 [low]; 3.27 vs. 4.04, p<.001 [medium]; 3.27 vs. 4.04, p<.001 [high]). There was no significant difference between any of the follow-up groups. For the belief determinant in Namibia, believe HIV tests are reliable, the relationship between exposure and scores was statistically significant (p<.001) but mixed. Those in the baseline group scored significantly higher than those in the no, low, and medium exposure follow-up groups, but not the high exposure follow-up group (3.77 vs. 3.59, p<.05 [no exposure]; 3.77 vs. 3.40, p<.001 [low]; 3.77 vs. 3.53, p<.01 [medium]). Those in the high exposure follow-up group only differed significantly from the low exposure follow-up group (3.67 vs. 3.40, p<.05). These mixed results may be due to the fact that between the survey rounds, the HIV test changed from ELISA testing to rapid HIV testing, about which Namibian public officials were wary. The threat determinant for perception of risk in the community showed a statistically significant relationship with exposure (p<.001), though not in the expected direction. Perceived threat was significantly higher at baseline in comparison with all of the four follow-up groups (4.05 vs. 3.70, p<.001 [no exposure]; 4.05 vs. 3.64, p<.001 [low]; 4.05 vs. 3.66, p<.001 [medium]; 4.05 vs. 3.74, p<.001 [high]); there was no significant difference between any of the follow-up groups. The reason for the lower perception of risk at follow-up is unknown, but may be due to increased access to treatment reducing the perceived threat associated with HIV. The final threat determinant, the percentage of respondents who knew someone who had died of AIDS, varied significantly with exposure (p<.001). A higher percentage of those in the baseline group knew someone who died of AIDS in comparison with those in the no, low, and medium exposure follow-up groups (65.3% vs. 49.2%, p<.001; 65.3% vs. 55.4%, p<.01; 65.3% vs. 58.8%, p<.05, respectively). Those in both the medium exposure follow-up group and the high exposure follow-up group reported a higher percentage than those in the no exposure group follow-up (58.8% vs. 49.2%, p<.05; 62.6% vs. 49.2%, p<.01, respectively)

25 Table 5: Impact of PSI social marketing interventions on HIV testing and on opportunity/ ability/motivation-related predictors of testing, Kenya, Namibia and Zimbabwe INDICATORS Country Baseline Follow-up segmented by exposure level None Low Med High Sig. BEHAVIOR Tested for HIV and received results ABILITY Knowledge Kenya 34.6 a 31.9 a 34.6 a 34.7 a 37.4 a Namibia 22.4 a 26.0 a,b 29.2 b 30.1 b 23.2 a,b Zimbabwe 19.5 a 27.7 a,b 23.7 a,b 31.1 b 31.7 b *** Know where to get tested for HIV Namibia 81.5 a 53.5 b 100 c 100 c 100 c *** Knowledge of MTCT (index) mean Kenya 2.76 a 2.62 a 2.98 b 3.00 a,b 3.01 b *** Self-Efficacy Self perceived ability to use condoms and abstain from sex (scale) Kenya 2.84 a 2.83 a 2.89 a 2.99 b 2.99 b *** Self perceived ability to use VCT services(scale) Zimbabwe 4.06 a 3.83 a,b 3.48 c 3.60 b,c 3.63 b,c *** MOTIVATION Attitudes Would buy products from HIV+ shop keeper Namibia 3.27 a 4.04 b 3.95 b 4.04 b 4.04 b *** Belief Believe HIV tests are reliable Namibia 3.77 a 3.59 b,c 3.40 c 3.53 b,c 3.67 a,b *** Threat Risk perception in the community Namibia 4.05 a 3.70 b 3.64 b 3.66 b 3.74 b *** Know someone who has died of AIDS Namibia 65.3 a 49.2 b 55.4 b,c 58.8 c 62.6 a,c *** Sig. = significance level. *p < **p < ***p < n.s. = not significant. Proportions with the same letter in their superscripts do not differ significantly from one another. DISCUSSION PSI s VCT interventions have grown from one pilot project in Zimbabwe to programs in over twenty-five countries worldwide. Experiences have shown that there is a need to both increase access to VCT as well as to create demand among those who are least likely to get tested. Despite increased financial, technical and human resources allocated to scaling up HIV testing services, over 80% of people living with HIV in resource-poor countries still do not know their HIV status (WHO, 2007). Even where HIV testing services are available, complex psychological, social and economic barriers prevent many individuals from learning their status (Hutchinson and Mahlalela, 2006; Fylkesnes and Siziyar, 2004). As a result, PSI has implemented social marketing programs to