The value of population campaigns offering free-of-charge HIV-testing: Observational study in a town in Cameroon

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1 Norsk Epidemiologi 2005; 15 (2): The value of populatio campaigs offerig free-of-charge HIV-testig: Observatioal study i a tow i Cameroo Kut Holtedahl 1, Leoard Booo 2 ad Daiel Salpou 3 1) Istitute of Commuity Medicie, Uiversity of Tromsø, Norway 2) Hôpital Provicial, Ngaoudere, Cameroo 3) Hôpital Protestat, Ngaoudere, Cameroo Corrrespodece: Kut Holtedahl, telephoe: telefax: kutare.holtedahl@ism.uit.o ABSTRACT Backgroud: HIV testig is ecouraged, but i may coutries testig is rarely free of charge except durig campaig periods. Aim: To study experieces from four years of campaig week for HIVtestig i the tow of Ngaoudere, Cameroo. Data have bee collected ad recorded from hadwritte protocols i 2001, from pre- ad post-cousellig sheets i 2002, ad from laboratory protocols i Results: Seropositivity teded to icrease with icreasig age, female sex, umber of sex parters last five years ad with low educatioal level. Differet dimesios of kowledge about HIV was associated with less seropositivity. Oe of five persos tested ever came back to kow their result, but seropositivity i this group was ot higher tha for those who retured. Overall HIV prevalece durig the last three years of campaig testig was 9.0, a little higher tha WHO atioal figures for Cameroo. Coclusios: HIV campaigs icludig testig may stimulate iterest ad kowledge about HIV, which is importat to lower HIV icidece. The HIV vulerability of females was cofirmed. Campaigs did ot easily attract less educated persos, ad campaig testig prevalece therefore could be expected to be lower tha HIV prevalece i the local populatio. O the other had, people with high risk behaviour may be over-represeted, icreasig campaig testig prevalece. Most asymptomatic persos receivig a positive test did ot come back for medical follow-up. Scietific evidece of the efficacy of triple combiatio atiretroviral therapy exists sice 1996, but treatmet is expesive. Geeral social security based access i rich coutries, ad paid access for rich people i poor coutries, created a ethically as well as medically justified demad for highly active atiretroviral therapy (HAART) i poor coutries. The differece i treatmet possibilities is especially visible i Africa, which carries the mai burde of the epidemic. HAART was itroduced i the regio of Adamawa i Cameroo from 2001, as part of the Natioal HIV/AIDS Program subsidised by the WHO ad other iteratioal orgaisatios. A day hospital uit was opeed ad a therapeutic committee was formed at the Provicial hospital, oe of the two hospitals i the tow of Ngaoudere with roughly ihabitats. A medically led Techical group has from 2001 orgaised a week of volutary, free-of-charge HIV testig aroud the iteratioal AIDS day 1 December. A systematic pre-cousellig was give by traied health persoel, ad the test results were give i a postcousellig sessio oe week later. We wated to study who came for testig, what they kew about HIV, how may came back for the results ad who had a positive test. Based o the data we reflect upo beefits ad limitatios of such testig i the fight agaist HIV. MATERIAL AND METHOD The umber of persos tested for each of the four cosecutive years was: 534, 866, 661 ad 344, respectively. Because of problems with the testig procedures i 2001, the aalyses preseted here iclude data from the years oly. I 2002, the cousellig sheets for 99 persos disappeared, ad 767 of the total 866 persos were icluded for further aalyses. A first egative test was accepted as a fial result. A positive result was always checked by a secod test, ad if ot cocordace, by a third test performed at a Cetre Pasteur laboratory i the tow of Garoua, 275 km away. From 2002, Determie was used as a first test ad Immuo-Comb as the secod test. The idea is to start with a highly sesitive test to have as few false egatives as possible, ad cofirm positive tests with a highly specific test to avoid false positives (1). Data were recorded ad aalysed i SPSS ( Chi square test was used for compariso betwee groups for categorical variables,

2 160 K. HOLTEDAHL ET AL. ad t test for cotiuous variables. Logistic regressio aalyses were performed for assessig associatios of HIV seropositivity with potetial determiats. The fial logistic regressio model was determied based o aalyses of bivariate associatios betwee seropositivity ad variables that could reasoably ifluece seropositivity, ad o elimiatio of some variables ot showig idepedet associatio i iitial models. Permissio to trasfer data from paper protocols ad cousellig forms to a aoymous data file was give by the provicial head of public health i Ngaoudere. A committee of ethics was i preparatio at the provicial hospital but had ot yet started fuctioig i The Regioal Committee for Medical Research Ethics i Wester Norway (REK III) was cosulted about a HIV therapy project usig routie cliical data to improve quality. Based o their judgemet that this did ot eed approval of the Committee, o separate applicatio was made for the curret registratios. RESULTS The prevalece of HIV-seropositivity was 9.0 amog all persos attedig the campaig testig durig the years I 2002, females beig tested had a mea age of 25.6 years (95 cofidece iterval ), males 29.1 years (95 CI ). persos had a mea age of 30.0 years (95 CI ), ad seroegative persos 27.3 years (95 CI ). For each sex separately, the differece is sigificat for males (P = 0.001) but ot for females. Tables 1-3 show that seropositivity teded to icrease with female sex, icreasig age ad umber of sex parters, ad with less schoolig. The last fidig is stregtheed by a iverse relatioship betwee kowledge about HIV ad seropositivity i both females ad males (table 2). The umber of sex parters reported the last five years was o average 2.5 for females (95 CI ) ad 4.9 for males (95 CI ). persos reported a mea umber of 4.9 sex parters (95 CI ) ad seroegative persos 3.7 (95 CI ). For each sex separately, this differece is sigificat for females (P = 0.009) but ot for males. Females who came to volutary testig had higher seropositivity tha males throughout the years of campaig testig (table 1). If seropositive, females teded to have had a earlier sex debut tha males (P = 0.027) ad females were more ofte umarried tha males (P = 0.008). Males had more parters also for the seroegative group (P<0.001). Seroegative males had a ew parter last 4 moths more ofte tha seroegative females (P = 0.001) ad teded to have had a earlier sex debut (P = 0.015) ad report regular codom use more ofte tha seroegative females (P = 0.002). Males who are frequetly o travel ad females who sell sex are well kow risk groups ad are probably represeted amog males with mobile professios ad umarried females, especially those classified as uemployed (tables 1-2). Regular codom use was reported more frequetly i seroegative tha i seropositive persos although this relatioship was ot sigificat for each sex separately ad i logistic regressio models. Oe of five persos tested ever came back to kow their result, but seropositivity i this group was ot higher (table 1). There was o differece betwee age groups whe it came to kow the result. However, seropositive persos more ofte had kept to themselves that they had bee tested (table 2). Oe seroegative ma was the oly oe who said he had had sex with me. Oe woma said she feared beig seropositive because she kew her husbad had had sex with me, ad her test was positive. Table 1. Seropositivity i relatio to professio ad commuicatio of test results i HIV test campaigs durig for females (F) ad males (M). Sero- Positive F M F M F M Total Sero- Sero- Sero- Sero- Posiposiposiposi- N tive tive tive tive Professio Local work Mobile work a Uemployed b Studets/pupils Ukow 4 Came to kow the result Did come Did ot come All persos tested ad recorded* Not recorded, ot icluded i table a Truck drivers, soldiers, police b Housewives, people lookig for employmet, retired persos * Relatively more females were seropositive, 2002: P=0.002, 2003: P<0.01, 2004: P<0.02

3 THE VALUE OF HIV CAMPAIGN TESTING 161 I additio to the December campaig testig, a separate campaig aimed at uiversity ad college studets i February 2003 revealed oly 10 cases of seropositivity amog 310 studets (table 4). Durig ocampaig periods, altogether 1665 tests i 2003 ad 2828 tests i 2004 were performed at the day hospital at a subsidised price of approximately 1.5 USD paid by the patiet. These tests were performed both i asymptomatic persos who wated the test, ad i persos referred by health persoel o the basis of cosultatios for symptoms. A high but ukow proportio was iitiated o cliical grouds. Approximately were performed free of charge i cosetig asymptomatic pregat wome. The proportio of seropositive results was expectedly higher outside campaig periods (P<0.001 for both years). The proportio of persos who did ot come back for their results was also higher i o-campaig-tested persos (table 4). From 2002, HIV positive persos were offered a cotact with oe of the hospital s few lay HIV positive voluteers immediately after the post-cousellig by health persoel. This offer has bee accepted i more tha half of the cases, although we have o exact figures ad o evaluatio of the value of such talks. All seropositive persos also got a appoitmet with a medical doctor oe to two weeks later, but oly a small proportio, perhaps per cet, have come back for these appoitmets with laboratory examiatios ad formal registratio as a HIV patiet. Agai, we have o figures, but this seems differet from people who test positively o cliical grouds. They usually come back to see their referrig health professioal, icludig a visit to the medical doctor. Table 2. Characteristics of persos tested i 2002, i relatio to seropositivity for females ad males.* Females (N = 321) Males (N = 446) P-value P-value Schoolig <0.001 Noe years years Marital status <0.001 Married, moogamous Married, polygamous Not married Number of sex parters New parter last 4 moths Yes No Age, sexual debut <16 years of age Codom use** Regular Not regular or ever Kowledge: cause of HIV <0.001 Virus Other cause Ca explai seropos. vs. aids Ca explai Caot explai Cofidece: Told about test <0.001 To o oe To someoe * Iformatio available for 767 persos of the 876 tested. ** Regular codom use was more frequet i seroegative tha i seropositive persos (P=0.026), but for each sex separately, this differece was ot sigificat.

4 162 K. HOLTEDAHL ET AL. Table 3. Associatio betwee seropositivity ad persoal characteristics based o logistic regressio aalyses of data from 2002.* Odds ratio** 95 CI Age i years (cotiuous) Sex (female=1, male=2) Number of sex parters last 5 years (cotiuous) Regular (=1) vs. ot regular (=2) codom use Schoolig (Noe=1, 1-8 yrs=2, >8yrs=3) * 151 persos with icomplete data were excluded ** OR > 1 for icreasig age, female sex, icreasig umber of parters, ad less schoolig. For codom use, OR 2.2 for ot regular use was ot sigificat From 2002, discordat tests ad tests with ucertai results have become exceptioal. However, i spite of a very good cotrol system at the local laboratory, oe positive result was commuicated to a seroegative perso who had got two umbers because waitig time had made her leave ad come back for testig. It was discovered because the shocked youg woma claimed she was a virgi. Subsequet double testig was egative ad the error foud. Durig the 2002 campaig, three lay HIV positive voluteers retested themselves ad oe was foud to be egative. She had falsely tested positively three years earlier ad had o moey for a secod, cofirmatory test, which she cosidered superfluous because she had suspected beig HIV positive. DISCUSSION For the overall poor populatio i Ngaoudere ad i most Africa coutries i geeral, campaigs offerig free-of-charge testig may be a good idea to promote kowledge about the HIV epidemic ad to give people a opportuity to kow their HIV status. Our study cosistetly cofirms the importat role of specific HIV kowledge as well as of educatio i geeral i prevetig ew cases of HIV. Pre- ad postcousellig is well orgaised i Ngaoudere ad may cotribute to better iformatio. A large proportio of the populatio still have o or little formal schoolig. I a previous study i Ngaoudere with a relatively high populatio represetativity, it was foud that half of all wome i fertile age had o schoolig at all, ot coutig choraic schools i this mixed Moslem-Christia populatio (2). I the HIV cotext, it tells that this is a vulerable populatio where iformatio ad local iitiative are importat. The upstart of the therapeutic era should ot be uderestimated for what it gives i terms of hope ad icreased iterest (3,4), however difficult it is to itegrate log-term treatmet i a culture with a weak ad ofte failig health structure (5). These cultural ad structural difficulties are illustrated i the study by the high umber of people ot comig back for their results, ad by the high umber of ewly diagosed but mostly healthy-feelig HIV positive persos who do ot come to their scheduled cosultatio with a medical doctor. Campaig testig more tha cliically based testig icreases the group of people who kow they are seropositive but who do ot receive post-test cousellig ad medical follow-up that might reduce their probability of spreadig the ifectio. Lack of ability to pay is a problem i this populatio. May persos comig for campaig testig say they would ot have come durig the year, whe they have to pay a subsidised fee. Eve if campaig testig is free of charge, the laboratory work-up ad further follow-up for seropositive persos cost moey, eve if oe omits the more expesive tests like viral load ad some serological tests. CD4 is aalysed locally ad is less expesive. It is possible to follow patiets through good cliical evaluatios ad a miimum of cheap blood tests, but doctors who are forced to practice i a very deprived ad ofte loely medical reality the receive little learig ad stimulus to improve their cliical practice. I Ngaoudere, a ecoomic aalysis of the patiet s possibilities to pay durig the ext two to three years always accompaies the cliical evaluatio whe the therapeutic committee takes a decisio about startig therapy. Dramatically lowered drug prices have helped a high umber of people, but regular paymet is still beyod the meas of most idividuals. May receive help from their exteded family ad are thus accepted for therapy. It is ot oly a questio of HIV drugs, but also of prophylactic ad therapeutic medicatio agaist opportuistic ifectios. It is probably difficult for Wester people to imagie to what extet ordiary people icludig the miority who Table 4. Seropositivity of HIV i data from campaigs ad durig cliically idicated testig i Females Males Females Males December campaig for all Studet campaig, February Regular testig rest of the year Did ot come for the result

5 THE VALUE OF HIV CAMPAIGN TESTING 163 are employed are ecoomically poor, ad how it affects their daily life ad their possibility to buy oecessities (6). As a group, the campaig tested persos are much better educated tha the average populatio. The separate studet campaig as well as the aalysis of professios i the 2002 campaig shows that this particular group has relatively little seropositivity compared with other people beig tested. It might thus seem probable that seropositivity i the adult populatio is higher tha the 9.0 durig the last three campaig years. WHO classifies Cameroo as a high burde coutry with a estimated HIV prevalece of 6.9 for the age group years at the ed of 2003 (7). A more recet survey i 2004 based o households has give a lower estimate of 5.5 for the whole coutry (Daiel Salpou, persoal commuicatio). Possibly the campaigs actually attract a segmet of the populatio havig some suspicio that they might be seropositive. The fidig that relatively more seropositive persos had kept their testig for themselves may give some support to such a hypothesis. It is ot ureasoable that more educated persos reflect more upo curret public HIV iformatio. This could explai that campaig seropositivity eve i a better educated segmet of the populatio could be higher tha atioal figures based o surveys. Natioal estimates used to be higher for the Adamawa provice tha for the rest of the coutry, ad this is still so i the 2004 survey with a prevalece of 6.9 (Daiel Salpou, persoal commuicatio). The HIV-prophylactic effect of codom use is well established. I the preset study, a higher seropositivity for o-regular users is suggested but did ot reach statistical sigificace i the logistic regressio model (table 3). The effect may have bee weakeed i our study if people with more parters ted to be more regular codom users. Such a hypothesis is supported by a higher proportio of regular codom users amog seroegative males tha amog seroegative females, ad the higher umber of sex parters the last 5 years for males. The importace of reducig the umber of sex parters is cofirmed i this study. The higher seropositivity of females is very cosistet ad probably reflects more tha a selectio bias due to differetial attedace at the campaig testig. The higher seropositivity i umarried females ad i females havig had a early sex debut stregthes the impressio of a HIV vulerable female populatio, ad females are also cotamiated at a youger age. Female biological as well as social vulerability for HIV is well kow (8,9). Extreme examples of the latter durig the campaigs iclude oe woma beig tested after mass rape by soldiers i a war area i a eighbourig coutry, ad a female uiversity studet reportig that she etertaied a relatioship to a married ma because this was the oly way she could pay for her studies. Beig HIV positive is clearly associated with great stigma, i this study suggested by a higher rate of seropositive people keepig the testig results for themselves. There are few volutary cousellors i the local group of HIV positive people, but those who participate i the educatio of the populatio ad i support of fellow HIV positive persos may have a sigificat impact o relievig the stigma (10). CONCLUSION HIV campaigs icludig testig may stimulate iterest ad kowledge about HIV, which is importat to lower HIV icidece. Campaigs have problems i attractig less educated persos, ad most asymptomatic persos receivig a positive test result did ot come back for medical follow-up. The HIV vulerability of females was cofirmed. Our results idicate that all programmes for HIV-testig ad ecessary follow-up should be publicly paid. ACKNOWLEDGEMENTS Dr. Emmauel Foudje was i charge of the HIV Techical Uit i ad participated i the plaig of the study ad i creatig the cousellig form. We have ot bee able to get i touch with him after he left Ngaoudere. Laboratory techicia Ali performed the laboratory tests ad has bee very helpful i providig laboratory data. Cotributio of the authors: Leoard Booo has from 2002 bee the mai resposible physicia for HIV treatmet at the Provicial Hospital ad did follow-up of sero-positive patiets. Daiel Salpou is i charge of a ati-hiv program orgaised by the Protestat church i collaboratio with the Protestat Hospital. Kut Holtedahl has visited Ngaoudere several times the last 20 years ad has had temporary egagemets at the Provicial Hospital. He has sporadically participated i differet medical aspects of HIV care. All the authors participated i plaig the study, i desigig the cousellig form, i recordig or orgaisig recordig of data ad i the elaboratio of the mauscript. KH had the idea ad wrote the first draft. LB ad KH also participated i cousellig. Declaratio of iterest: Noe for all the authors.

6 164 K. HOLTEDAHL ET AL. REFERENCES 1. Koblavi-Dème S, Maurice C, Yavo D, Sibailly TS, N'guessa K, Kamela-Tao Yea. Sesitivity ad specificity of huma immuodeficiecy virus rapid serologic assays ad testig algorithms i a ateatal cliic i Abidja, Ivory Coast. J Cli Microbiol 2001; 39: Holtedahl K, Hurum H. Cross-sectioal study of morbidity, morbidity-associated factors ad cost of treatmet i Ngaoudere, Cameroo, with implicatios for health policy i developig coutries ad developmet assistace policy. BMC Iteratioal Health ad Huma Rights (2), 3. Gayle H, Lage JMA. Seizig the opportuity to capitalise o the growig access to HIV treatmet to expad HIV prevetio. Lacet 2004; 364: Gazzard B. Atiretroviral therapy for HIV: medical miracles do happe. Lacet 2005; 366: Editorial. Mexico, 2004: Global health eeds a ew research ageda. Lacet 2004; 364: Feto L. Prevetig HIV/AIDS through poverty reductio: the oly sustaiable solutio? Lacet 2004; 364: WHO facts about HIV Tlou SD. Geder ad HIV/AIDS. I: Essex M, Mboup S, Kaki PJ, Marlik RG, Tlou SD, eds. AIDS i Africa. New York: Kluwer Academic/Pleum Publishers, 2002: Klouma E. Wome at risk. Populatio based research o HIV, sexually trasmitted ifectios ad geital cuttig i Norther Tazaia (Thesis). Oslo: Departmet of Geeral Practice ad Commuity Medicie, Uiversity of Oslo, Norway, Merrima A, Kaur M. Palliative care i Africa: a appraisal. Lacet 2005; 365:

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