Evaluation of Current Community-Based Operational HIV Testing and Counselling Strategies in Urban and Rural Settings of Tanzania

Evaluation of Current Community-Based Operational HIV Testing and Counselling Strategies in Urban and Rural Settings of Tanzania

Williams H Makunde1, Isolide Massawe1, Filbert Francis1, Calvin Sindato1, Erick J Mgina2, Akili Kalinga2

1Tanga Medical Research Centre
2Tabora Medical Research Centre
3Tukuyu Medical Research Centre

  1. *Corresponding Author: Dr. Williams H Makunde, Tanga Medical Research Centre. Email: hwmakunde@hotmail.com

Abstract

Background: Health facility-based provider and client-initiated HIV testing and counselling (HTC) strategy is the globally used strategy. However, in Tanzania, 85% of eligible individuals have not been able to test for HIV to date. It is for these reasons, alternative strategies using community-based HIV testing and counselling (CBHTC) approaches was adopted.

Methods: This was a descriptive, cross–sectional study carried out in Tanga, Tabora, and Mbeya regions of Tanzania using quantitative and qualitative data collection methods.

Results: A total of 5,583 individuals were interviewed.  Majority 94.4% of the participants were aware of the CBHTC strategies. The levels of awareness was higher among participants from urban (91.6%) compared to rural (89.9%) (χ2=4.4, p=0.035) settings. There was a significant variation in the level of awareness across study sites (χ2= 41, p<0.001). Two-third (67.5%) of participants reported that they have tested for HIV. Of which females accounts for high proportion (71.8%) compared to males (61.3%) (χ2 =66.6, p<0.001). The Level of awareness increased the likelihood of utilization of HIV testing and counselling services (OR=2.92, 95% CI: =1.55 -5.48, p<0.001).

Conclusions: These results have demonstrated an outstanding level of awareness on CBHTC services among study participants in the study areas. Individuals who were aware of CBHTC strategy were more likely to test for HIV compared with their counterpart who had no awareness. These results also, indicated that CBHTC strategy would attract more males to participate in HIV testing compared to health facility based strategy.

Keywords

HIV Community testing & counseling; client initiated; Provider-initiated; health facility; Tanzania

Introduction

HIV has remained the major public health problem globally since it emerged in the 1980s, whereas Sub-Saharan Africa (SSA) region presents the highest burden. The region has 25.5 million people living with HIV accounting for 69.2% of the global cases [1] and 2 million new cases of infections existing towards the end of 2016. Despite the gradual increase in HIV testing in recent years in most of sub-Saharan African countries, more than 50 % of individuals  living with HIV do not know their sero- status [2]. Current estimates have shown only 70% of people with HIV know their status. In order to achieve the targeted 90% accessibility an additional 7.5 million individuals should access HIV care and treatment services within community or facility linked [3]. However, in the mid of 2017, there was an increased in the number of individuals living with HIV receiving antiretroviral therapy (ART) globally [3]. This increase of people on ART globally and particularly in sub-Saharan Africa has been accelerated through the introduction of HIVST kits (HIV self-testing) at communities linked to health facilities for prompt ARTs initiation [4,5]. In Tanzania the prevalence of HIV has been decreasing over the years reaching overall estimates of 4.7% in adults with regional prevalence ranging from 0.2% in Zanzibar to 15.4% in Njombe [6]. On the other hand, the annual incidence of HIV among adult’s ages 15 to 64 years in Tanzania is now 0.3% while among the females is 0.4% and 0.2% among males. A high prevalence was reported among adult women (6.5%) age category 15-64 whereas among the males was 3.5% of the same age category [6].

Studies have shown that, an impact on HIV prevalence reduction is largely influenced by linkage between HTC strategies, care and treatment services [7,8,9]. In the context of scaling-up accessibility, awareness and acceptability, there is a need to emphasize and advocate on, fear of stigma, discrimination, perceived lack of confidentiality, the inconvenience and opportunity costs of testing [2] If all those parameters are taken on board, the population to be counselled tested for HIV infection and treated according to new WHO policy of prompt ART independent of CD4 levels will be high. On the other hand, a WHO mathematical model suggests that intensifying HIV testing, combined with antiretroviral therapy (ARTs), has the potential to reduce new HIV infections by 95% within 10 years [10]

In Tanzania HIV testing and counseling (HTC) services have been available since 1995 through Voluntary Counselling and Testing (VCT) in clinical settings. In 2007/2008 the Government of Tanzania introduced the provider-initiated testing and counseling (PITC) guideline to guide PITC operations in the country [11]. However, studies have shown that there is the low uptake of HTC services in different settings [12]. Despite the recent efforts to improve uptake and accessibility, acceptability and utilization of such services, it is still low in different areas in the country [13,14]. This low uptake and utilization are more pronounced in male than females [15, 16]. Poor acceptability of HCT services, HIV-related stigma, confidentiality, poor accessibility and fatalism have been reported as the barriers to utilization of HTC services in the majority of African settings [17]. It has been found that complementing facility-based HTC strategy with other strategies has the potential to improve access and utilization of HTC services and reduce HIV infections [17,18,19]

In Tanzania, efforts have been made to complement health facility-based HTC strategies with community-based strategies including home-based, door-to-door, household-index, events, campaigns, workplaces, schools/colleges, prisons and couples/partners testing. Besides the efforts, their uptake has remained low still. Level of access and utilization of community-based HTC services in Tanzania is not known explicitly. Therefore, this study was conducted to explore availability, acceptability, utilization, gender discrepancy and performance of community-based HTC strategies in the selected study sites. It is anticipated that the findings of this study will contribute to modifying and updating strategies for improving access and utilization of HTC services with ultimate goals of improving health care and reducing new infections.

Materials and Methods

Study design and sites

 This was a descriptive, cross-sectional study carried out between January 2014 and March 2015 in urban and rural settings of Tanga (north-eastern), Tabora (western), and Mbeya (southern highlands) regions of Tanzania. These three sites were selected to present the sites with higher to low HIV prevalence and geographical locations to allow comparative analysis of HTC service delivery strategies in these settings; Mbeya has the highest (9.0%).  HIV prevalence followed by Tabora (5.1%) and Tanga (2.4%) [20].

Study population and sampling procedures

 The study involved both urban and rural populations in Tabora Urban and Uyui districts (Tabora region); Tanga city and Muheza district (Tanga region); and Mbeya city and Rungwe district (Mbeya region). It was assumed that, there is unequal probability of individuals in the community to become sick, but only a few of those would consult health care facilities. A proportion of those who would not consult health care facilities was assumed to remain sick at home for some time and possibly would attend alternative places other than the standard medical care services. With this kind of assumed heterogeneity, the present study focused on recruiting participants from the general population, individuals at work places, college and boarding schools. Study information was provided to participants prior to enrolment. Those individuals who agreed to be involved in the study, written informed consent was obtained. Thumb prints were taken from Individuals who were unable to write.

Sampling procedure and sample size determination from the villages and streets

Multi-stage cluster and probability proportional to size sampling approach was used to select study participants. A cluster was defined as a village in the rural and street in the urban settings. A list of villages and streets in the study districts were obtained from district administrative authorities to establish sampling frame.  In the first stage, villages and streets to participate in the study were chosen randomly from the list provided using computer generated numbers.  Whereas in the second stage, households within each village and street were randomly chosen.

Whereby, 31 households from 20 villages in the rural and 20 streets in the urban were randomly selected to be involved in the study. All members in the household age ≥18 years present in the house at the time of interview were requested to participate in the interview if consented.

Sample size estimation for household members from the community level

The sample size was estimated using modified Kish and Leslie (1965) [21] formula. With the assumption that 50% of household members have ever tested for HIV, with a design effect of 1.5 which accounts for the variation associated with the sampling design. The minimum sample size required was

n= 

n=576

When the sample size adjusted for 10% non-responses, the final sample size required was 636 households.   Key: n= Sample Size; z = the standard normal value corresponding to the desired level of confidence (1.96 for a 95 percent confidence level); p =proportion household’s members respondent p= 0.50, e = marginal error of =5%. K is cluster design effect (measures of intercorrelation)  (k=1.5). The size of the cluster  (C)  was calculated using the formula shown below.

Where b = number of responses per cluster (village) = 20 (on average), z= corresponding value of 95% confidence interval, and e = marginal error, p= assumed proportion of respondents from previous study. The number of household visited in each village/street was calculated by dividing  n/C which is equivalent to 636/20 =31 households per villages/streets.

Sample size estimation for participants from  college and secondary schools

From each study site, one college and one boarding secondary school were randomly selected. With an assumption that 20% of students had tested for HIV/AIDS; 95% confidence interval; 5% margin error, the estimated minimum sample size of 300 students from each college and boarding secondary schools from each site was needed.

Sample size estimation for participants from working places

Convenient sampling approach was used to select numbers of individuals to be interviewed from working places. Two working places were randomly selected from each study site whereby 50 individuals were randomly selected from each working place and interviewed.

Data collection procedures

A semi-structured questionnaire was administered in Kiswahili to obtain the quantative data from study participants. Interviews were conducted to explore level of awareness and perceptions of individuals on availability of different HTC delivery strategies within the communities surveyed. In the interview the head of households were approached and asked the informed consent of the household to participate in the interview. All members aged ≥18years in selected household were interviewed by researcher assistant

Focus group discussions

The Focus Group Discussions (FGDs) were conducted in Kiswahili and aimed at exploring the practices, ideas, experiences and preferences related to HIV testing counselling strategies currently available at community level. Both male and female participants were interviewed separately in a group of ten individuals. Participants were asked for their consent before discussions were audio-recorded. Experienced and skilled social scientists were involved in the conduction of FGDs. One scientist served as the moderator for the focus group discussions and the second person served as the note-taker. The moderator lead the introduction of the purpose and main themes for discussion, conducting the discussions according to the interview guide and keeping the conversation flowing. Participants were given chance to thoroughly discuss the given themes and emerging ideas were followed up with further questions. The interview guide covered a broad range of topics related to HTC strategies and was flexible so as to encompass questions on emerging relevant themes. Emerging themes were carried forward and included in subsequent interviews for the validation and clarification of doubts. The duration of FGDs ranged from 45 to 60 minutes. Audio-recorded FGDs were transcribed and translated from Kiswahili to English. The information gathered from FGDs was used to complement and triangulate the quantitative results.

Ethical consideration and informed consent

Ethical approval

The study protocol was approved by the Tanzania Medical Research Coordinating Committee of the National Institute for Medical Research.

Data analysis

Quantitative data analysis

Data collected were double-entered by two independent data clerks and managed using MS Access. Open-ended responses were coded. Logical checks were built into the database to limit entry errors, and frequency runs were also made for all variables to ensure the accuracy and consistency of the data outputs. The analysis was performed using Stata version 11 software (Stata Corp, College Station, TX). Chi-square test was used to assess the association between categorical variables and Student-t-test and one way ANOVA were used to compare continuous variables. Logistic regression analysis was used to examine the association of potential independent variables with the level of awareness and utilization of HTC services. Odds ratios (ORs) with 95% confidence intervals were used to present effective size. Variables were initially screened at p=0.2 during the univariate analysis before they were considered in the multivariable logistic regression analysis using forward stepwise approach. Probability values (p-values) were considered significant at ≤0.05 level.

Qualitative data analysis

The audio-recorded FGDs were transcribed for content coding then followed by translation from Kiswahili to English language while maintaining the meaning of the culturally-embedded conception and expressions. Then thematic analysis in psychology according to Braun and Clarke 2006. The six steps of thematic analysis framework were adopted namely; familiarization of the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes and producing the report. The collected information in the field was given a code for confidentiality. The emerging themes were underlined before the results were deployed to reach key conclusions pertaining to the key findings in hand for this study. The main emerging themes were related to what was experienced as the value of counseling and testing at community and possible challenges experienced with the implementation of the current available community-based HTC models e.g. home-based, outreach, mobile services, campaign and event by the study participants.

Results

A total of 5,583 participants were enrolled in this study, 1,908(34.2%) from Mbeya, 1,825(33.0%) from Tabora, and  1,850(33.1%) fromTanga regions, respectively. A total of 3,676 (65.8%) of the participants were drawn from the community, 1664(29.8%) from learning institutions and 243(4.4%) from working places.

Socio-demographic characteristics of the participants

A total of 5,583 individuals with median (inter-quintile range) of 26 (20-39) were interviewed. The majority (58.5%) of the study participants were females and (47.6%) were of single marital status. Half (50.0 %) of study participants had acquired primary education and more than half (55.2%) were Christians (Table 1). Younger participants were interviewed in Tabora compared to Tanga and Mbeya study site (F=35.4, p<0.001).

 

Variable Overall (n=5,583) Study sites
Mbeya (n=1,908) Tabora (n=1,825) Tanga (n=1,850)
Sex, n (%)
Male 2,317(41.5) 881(46.2) 670(36.7) 766(41.4)
Female 3,266(58.5) 1,027(53.8) 1,155(63.3) 1,084(58.6)
Age mean (IQR) 26(20 -39) 26(20 – 38) 24(19 -35) 28(20 – 43)
Education, n (%)
None 539(9.7) 176(9.2) 155(8.5) 208(11.3)
Primary 2,793(50.0) 821(43.1) 1,056(57.9) 916(49.5)
Secondary 1,677(30.0) 544(28.5) 604(33.1) 529(28.6)
Post-secondary 574(10.3) 367(19.2) 10(0.5) 197(10.7)
Marital-status, n (%)
Single 2,658(47.6) 809(42.4) 927(50.8) 924(49.9)
Married 2,548(45.6) 966(50.6) 777(42.6) 805(43.5)
Widow/widower 216(3.9) 89(4.7) 63(3.5) 64(3.5)
Divorced/separated 161 (2.9) 44 (2.3) 58 (2.1) 58 (3.1)
Occupation, n (%)
Peasant 1,999(35.8) 663(34.8) 808(44.3) 528(28.5)
Employed 382(6.9) 145(7.6) 113(6.2) 124(6.7)
Student 1,895(33.9) 632(33.1) 635(34.8) 628(34.0)
Non-employed 1,307(23.4) 468(24.5) 269(14.7) 570(30.8)
Religion, n (%)
Muslim 2,005(35.9) 149(7.8) 873(47.8) 983(53.1)
Christian 3,082(55.2) 1,340(70.2) 885(48.5) 857(46.4)
Others 496(8.9) 419(22.0) 67(3.7) 10(0.5)

 

Table 1: Demographic characteristics of study participants

Level of awareness on the CBHTC strategies

Among 5,583 participants interviewed majority (94.4%) were aware of the CBHTC.  Significantly higher level of awareness was reported among participants from Tanga (94.2%, 1,744/1,850), followed by Mbeya (89.2%, 1,702/1,908) and Tabora (88.8%, 1,620/1,825), respectively (X2 =41, p<0.001).  Male (91.0%, 2,109/2,317) were more aware of CBHTC strategy as compared to females (90.5%, 2,957/3,266), although the difference was not statistically significant (p=0.539). There was statistical evidence on the variation of the level of awareness of CBHTC strategy between individuals from urban (91.6%, 2,588/2,827) and rural (89.9%, 2,478/2,756) settings (X2 =4.4, p=0.035).  Individuals with post-secondary education reported higher level of awareness on CBHTC (90.6%, 520/574), followed by secondary education (87.6%,  1,451/1,676),  primary education (85.1%, 2,778/2,794) and with no education (82.2%, 443/539) and the difference was statistically significant (X2 =93.0, p<0.001).On another hand, a high level of awareness on CBHTC strategy was also observed among separated participants (96.3%, 154/160) and married (94.0%, 2,395/2,548) and the difference was statistically significant (X2 =74.5, p<0.001). Furthermore, the level of awareness on CBHTC was higher (93.8%, 228/243) among individuals interviewed from working place compared to communities (92.8%, 3,411/3,676) and learning institution, (85.8%, 1,427/1,664) (X2 =70.0, p<0.001). At community level, majority (93.0%, 1,279/1,375) of the male were more aware of the CBHTC compared to females (92.7%, 2,132/2,301) (p=0.681). At institution level; males accounted for just over half (51.0%) of 1,664 individuals who reported awareness on CBHTC strategy (p=0.076). Contrary, at workplaces, the high proportion (94.4%, 134/142) of females were aware of the CBHTC strategy. The level of awareness was evidenced further during the FGDs conducted in the three study sites. For example, some participants commented that– “…. others came with tents in the village and conduct counselling and testing and gave out the results on the same day after testing” (male FGD Mbeya).

 “….I have seen it during the blood donation which is goes hand in hand with HIV testing in our place” (female FGD Tabora).

 

Variable Un adjusted OR (95% CI) P-value Adjusted OR (95% CI) p-value
Region    
Tabora ref ref.
Mbeya 1.04(0.85 – 1.28) 0.670 0.96(0.78 – 1.20) 0.744
Tanga 2.08(1.63 – 2.65) <0.001 2.16(1.68 – 2.78) <0.001
Institutions
Collage/school ref
Community 2.14(1.77 -2.56) <0.001 1.15(0.86 – 1.56) 0.334
Working place 2.52(1.47 -4.33) 0.001 1.47(0.82 – 2.62 0.188
Education
None ref ref
Primary 1.37(1.29 – 2.45) <0.001 1.34(1.31 – 2.58) <0.001
Secondary 0.72(0.47 – 0.89) 0.008 0.96(0.66  – 1.40) 0.845
Post-secondary 1.07(0.72 – 1.59) 0.731 1.51(0.95 – 2.42) 0.081
Religion
Non-Christian ref ref.
Christian 1.30(1.11 – 1.60) 0.002 1.58(1.32 -1.92) <0.001
Age group (years)
<24 ref ref.
24-39 2.23 (1.77 – 2.81) <0.001 1.28(0.94 – 1.75) 0.109
>39 1.97(1.55 – 2.51) <0.001 0.98(0.71 – 1.37) 0.942
Marital status
Single ref
Married 2.27(1.86 – 2.77) <0.001 1.57(1.20 -2.01) 0.001
Widow/widower 1.34(0.84 – 2.14) 0.208 1.01(0.62 – 1.84) 0.793
Separated/divorced 3.72(1.63 – 8.49) 0.002 2.60( 1.11 – 6.12) 0.028

 

Table2: Logistic regression model assessed association between the awareness of community-based HIV testing and Counselling Services

Factors associated with level of awareness on CBHTC strategies

Univariate logistic regression has been used to assess the association between age, study site, gender and marital status regarding the level of awareness on CBHTC. The level of awareness was significantly higher among individuals aged 24-39 years by 2times (OR=2.23, 95%CI= 1.77-2.81, p<0.001) and by 97% among individuals aged ≥39 years (OR=1.97, 95%CI=1.97 -2.51, p<0.001) as compared to those aged<24years old. The level of awareness was significantly two times higher among participants from Tanga (OR=2.08, 95% CI =1.63 – 2.65, p<0.001); as compared to the two study sites (Mbeya) (OR=1.04, 95% CI=0.85 – 1.28, p=0.670) and Tabora.  On the hand, the level of awareness among individuals from workplaces was higher by 2.5 times (OR=2.52, 95% CI = 1.47-4.33, p=0.001); from the community by 2.14 (OR=2.14, 95% CI=1.77- 2.56, p<0.001) as compared to learning institutions. Similarly higher level of awareness was reported among married couples, widow/widower and separated as compared to single (Table 2). Adjusted for study region, institutions, education status, religion, age and marital status, high level of awareness was reported among individuals from Tanga site (AOR=2.16, 95% CI=1.68 – 2.78,p<0.001) compared with those from Tabora site, having attained post-secondary education by 51% (AOR=1.51, 95%CI=0.95 – 2.42, p=0.081),being a Christian  (AOR=1.58, 95% CI=1.32 – 1.92, p<0.001), and being married (AOR=1.57, 95% CI=1.20 – 2.01, p<0.001)  and separated/divorced  (AOR =2.60, 95% CI= 1.11 – 6.12, p=0.028) (Table 2).

 

Variable Un adjusted OR

(95% CI)

P-value Adjusted OR (95%CI) P-value
Awareness of CBHTC        
No ref ref.
Yes 2.3(1.91 – 277) <0.001 2.92(1.55 -5.48) 0.001
Region    
Mbeya ref ref.
Tabora 1.15 (1.01 – 1.32) 0.037 1.42(1.13 – 1.79) 0.003
Tanga 1. 35(1.18 – 1.55) <0.001 1.74(1.41 – 2.16) <0.001
Level    
Learning institution ref ref.
Community 2.95(2.61-3.33) <0.001 2.65(2.09 – 3.37) <0.001
Working place 5.96(4.11- 8.63) <0.001 1.3(0.90 – 1.88) 0.158
Sex    
Female ref ref.
Male 1.61(1.43- 1.80) <0.001 1.23(1.03 – 1.45) 0.02
Education    
None ref ref
Primary 2.48(2.01- 3.01) <0.001 0.69(0.50 – 0.96) 0.029
Secondary 1.06(0.87 -1.29) 0.539 1.61(1.16 – 2.24) 0.004
Post-secondary 1.95(1.49-2.45) <0.001 1.17(0.79 – 1.72) 0.432
Setting        
Rural ref ref
Urban 1.30(1.16- 1.45) <0.001 1.14(1.01 -1.29) 0.03

 

Table 3: Final multivariable logistic regression model for utilization of community-based HIV testing and Counselling Services

Sources of information about CBHTC strategy

The frequently mentioned sources of information about CBHTC strategy included radio/televisions (89.9%), health worker (68.9%), relative/friend (65.3%) and newspapers (57.2%) and the least was religious leaders (Figure).

Figure:  Responses about the sources of information on the Community-Based HTC strategies

Utilization of HIV testing services

Majority 67.5% (3,718) of study participants mentioned that they have tested for HIV. Of those, (79.2%, 2,946/3,718) and (20.8%, 772/3,718) tested through health facility and community levels, respectively. There was a significant variation of individuals tested for the HIV between study sites (χ2=21, p<0.001). Among the individuals who tested at the community, the majority were from Tanga site (40.7%, 316/772) and a small proportion from the other two sites (Mbeya & Tabora) (p<0.001).

Females accounted for (66.5%, 1,960/2,946) of individuals tested for HIV at health facilities whereas males accounted for (53.1%, 410/772) of individuals who tested for HIV through CBHTC strategy (p<0.001). Almost two third (54.2%, 3,026/5,583) of study participants were of the opinion that the CBHTC strategy would attract more males and/or male partners to test for HIV, and (57.1%, 2,694/4,717) thought that the strategy would reduce HIV/AIDS-associated stigma in the community. Participants of FGDs were of the opinion that CBHTC strategies would enhance participation of males in the programme “I think home based (door to door) strategy is the best one because my husband is likely to become reluctant to accompany me to hospital for HIV testing. However, he is more likely to participate when HIV testing service is offered at household level” (female FGD

Factors associated with utilization of HIV testing services

Overall, individuals who were aware of CBHTC strategy were two-fold more likely to test for HIV compared to those who were not aware (OR=2.30, 95% CI= 1.91 – 2.77, p<0.001).   The likelihood of utilizing HTC services was higher among individuals from Tabora (OR=1.15, 95%CI= 1.01 – 1.32, p=0.037) and Tanga (OR=1.35, 95%CI=1.18 – 0 1.55, p<0.001) compared to Mbeya site. The individuals from community and workplaces had three times (OR=2.95, 95%CI=2.61 – 3.33, p<0.001) and six times (OR=5.96, 95%CI=4.11 – 8.63, p<0.001) odds of testing for HIV as compared to those from institutions. Utilization of HTC services was 30% higher in urban compared to rural settings (OR=1.30, 95%CI=1.16 -1.45, p<0.001). Overall, females were 1.6 times more likely to test for HIV compared to males (OR=1.61, 95%CI= 1.43 – 1.80, p<0.001). The odds of testing for HIV for individuals with the primary and post-secondary level of educations were (OR=2.48, 95%CI=2.01 – 3.01, p<0.001) and (OR=1.95, 95%CI=1.49 -2.45, p<0.001) as compared to those without any education (Table 3)

Adjusted for region, institutions, education status, sex, and settings (urban or rural) , the level of awareness of the CBHTC strategy was the most significant factor for utilization of CBHTC services (AOR=2.92, 95% CI=1.55 – 5.48). Other factors included region of residence; being from Mbeya (AOR=1.42, 95%CI=1.13 – 1.79) and Tanga (AOR = 1.74, 95%CI= 1.41 – 2.16) regions than residing from Tabora, being from higher learning institution (AOR=2.65, 95%CI=2.09 – 3.37) compared with those from community, and being a male (AOR=1.23, 95%CI=1.03 – 1.45). Individuals with secondary school level of education (AOR=1.61, 95%CI= 1.16 – 2.24) were more likely to report utilization of CBHTC services compared with those without any education. However, those with the primary level of school education were less likely (AOR=0.69, 95%CI= 0.50 – 0.96) to report utilization of CBHTC services compared with individuals without any education.

Discussion and Conclusion  

The findings of this work have shown a high level of awareness on community based HIV testing strategies in the study areas. Therefore, accessibility and utilization of HTC services in rural and urban at both facility and community setting has shown to be highly accepted in some settings in Africa where individuals did not know their sero-status [22]. In this study it has shown that, individuals residing in the urban were more likely to test for HIV than those in the rural settings. This could be due to the fact that, majority of the media used to disseminate information on health issues or political matters are based within the cities or big towns in the urban therefore members get access to information prompt and frequent as compared in the rural areas. Accessibility, acceptability, and utilization of HTC services is largely affected by three factors, which includes government involvement in HTC services, service provider characteristics, and the level of awareness of the communities. Conceptualization of these factors will subsequently result into increased HTC service provision, acceptability and utilization.

 

The results of this work has shown a high level of awareness on community based HIV testing strategy of (94.4%) indicating, the presence of the various CBHTC packages providing services in the communities both urban, rural institutional and work place. However, slight variation of the level of awareness was observed across the study areas, although in Tanga, it has shown the highest level as compared to the other study areas (Tabora & Mbeya). This could have been attributed to the current sensitization programme introduced in the country halting the HIV burden (15,14]. Similar findings of high level of awareness were reported in Uganda and Zambia, although home-based type of CBHTC was the preference [23, 24]. In this study, using logistic regression adjusted for highest level of education attained some variables such as; sex, age, religion, setting (urban/rural) age above 25 and duration of residence/stay are the best proxy indicator of increased level of awareness on CBHTC. Several observations on HIV/AIDS have shown that, women are more concerned /responsible for their health than men [25] possibly this is why in most cases when referring to those who are willing to test for HIV, majority of those who turn up are women especially at a health facility. This is also the case in this study where awareness is linked with increased awareness on CBHTC strategies. Similarly; age above 25 years is the period when many young adolescent acquire maturity a period when many of them have completed secondary schools, colleges and start to build up their capability of managing their own tasks. This was also true confirmed in this study, i.e. those individuals age above 25 years were likely better equipped with awareness on CBHTC strategies as compared to those below that age. On the other hand, since community members do not live in isolation within their environment, in terms of spiritual beliefs, among the important variable observed in the socio-demographic aspect is religion which carries substantial weight when referring to disease in humans because in some religious denominations during their prayers do also discuss how diseases are transmitted, prevented and in this study, the religious aspect was clearly demonstrated. Our results have shown that, majority of the study participants were aware of CBHTC strategy, however, female were more likely to report awareness on CBHTC strategy than males, although the difference was not statistically significant.

 

On the other hand, it has also shown in this study, even at institutional level HTC strategies are also operationalized and this was demonstrated in the three study sites whereas a large proportion of around 85% of the employees were tested for HIV/AIDS at their working places. These results concur with current needs for more accetable options to VCT or stand alone strategies such as work place, mobile and home-based HTCs [13,26] to increase and accelarate uptake with linkage to health facility-based VCT in different settings as observed in Kenya [27]. “The outreach strategy for example in working or business places is good and motivate people especially males because they spend very short time for testing”(Male FGD Mbeya).

 

It is also important to note that, the responses of those participants in those study sites on utilization of CBHTC varied significantly most likely due to cultural differences in those settings and education background. Therefore, a high proportion (89.9%)  of the responses  among those interviewed indicated that, the source of information on CBHTC was through radio/television probably this could have been influenced by the fact that its geographical setting  (urban ). This is also an area where health facilities are mostly located and easy to access. Possibly an economical factor could have been another reason because at a rural setting very few individuals own radio/television,therefore, their source of information on CBHTC would be less informative compared to big cities. Interestingly one of the FGD participant said that “ I remember Kihumbe they came, counselled and tested people. They reported at the executive officer; after testing some people received testing results and some did not receive results because they feared to receive them although in our case, we received the results” (female FGD Mbeya). These are some of the perception of the people when services are provided within the vicinity.

 

In learning institutions (boarding schools & Colleges), the results have shown that, even in those closed premises, students are willing to test and counsel without the influence of their teachers or parents. It is therefore crucial to promote these modes of strategies in those boarding schools, colleges and working places to increase access to prevention, care and treatment. Again it was in Mbeya site where majority of the students who claimed to have tested for HIV/AIDS was observed. In contrary to this, it was also in Mbeya, where  the general population was  less aware of CBHTC services despite of having an equiped HIV mobile laboratory and clinic its not clear why this occured. May be advocacy on CBHTC was not very well publised as required. Within those institutions it was clear that, the students originated from different areas in the country, for that matter, there might be some factors originating from their birth area which could influence their awareness on utilization of HTC services.

The findings of our work suggests that, since a relatively high proportion of participants (62%) said using CBHTC strategies (home-based) would encourage more men to come forward to test and counsel its important finding to consider and incorporate this type of stratgegy in the present  programme. “In their community male participation was higher than that of females and this is because females are fearful to know their status which cause them to run/change their living places” (male FGD Tanga).

 

It is therefore, important to adopt these findings as model to attract more men and increase access to them in this way. Many participants were satisfied with the privacy guaranteed by CBHTC. In some settings, studies have described involvement of families in seeking private counselling space within and outside the home, although preference was at home where results could be sheared without fear [28, 29,30].  It is known fact that, over the years, it has been difficulty to convince men to attend health facility based strategy to test for HIV/AIDS. In most cases majority of epidemiological studies, women are more open to attend VCTs/test and counsel for HIV/AIDS. “During the Global /International AIDS day it is when majority of the people test, even those sick also attend hospitals, where they are advised to test for HIV and also when  pregnant, they need to test for HIV. This can prevent the mother as well as the offspring” (female FGD Tabora). Although this model of CBHTC strategy has been suggested by a large proportion of the respondents interviewed to attract men, on the other hand, does not appear to motivate clients to disclose their HIV-sero status as compared to health facility based HTC [31,32]. The preference towards this community model of counselling and testing HIV is likely to be adopted because no transport cost incurred, time lost, and economic opportunities while attending CBHTC services.

The involvement of respondent in identification of private spaces within the home was considered as empowering them and improves increasing the uptake [25] of accepting the testing; in contrary to health facilities where patient have no role over the arrangement of testing and counselling.

Conclusion

The CBHTC strategies seem to be additional strategy offering HTC services better preferred in the studied areas. It has shown that, CBHTC strategy would attract more males to participate in HIV testing compared to health facility based strategy both provider and client initiated. Moreover, this CBHTC strategy appeared to reduce existing inequalities in access. Importantly, to what extent communities will accept and policy makers promote the community based HTC modes which might differ from a situation whereby it is offered as part of research as compared with the situation when such services are scaled up.

Author’s Contribution

WHM, CS, developed the idea and designed the study, and prepare the first draft of the manuscript whereas; FF, EM & AK managed the data collection & analysis. IM, FF EM supervised data collection. Finally, WHM, CS & FF interpreted the results.

Competing interest.

Authors declared no conflict of interest

 

Acknowledgement

We would like to thank the District Executive Directors, Regional Medical Officers, District Medical Officers and community leaders in Tanga, Tabora and Mbeya. We also extend our sincere thanks to the study participants and the research assistants who participated in data collection from the communities, health facilities and offices. We also recognize the Global Fund for enabling the resources to accomplish this study. NIMR the Global Fund Secretariat is also recognised for the support in the execution of the study. Not forgetting the NIMR Directors (Tanga, Tabora & Mbeya) for coordinating the study at the three different sites, similarly we would also thank the NIMR Director General (Prof Yunus Mgaya) for permitting publication of this work.

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