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Predictors of non-uptake of human immunodeficiency virus testing by tuberculosis public primary patients in three districts, South Africa

The acceptance of HIV testing among patients with tuberculosis (TB) is low in South Africa. The aim of this study was to assess the prevalence, associated factors and reasons of non-uptake of human immunodeficiency virus (HIV) testing by tuberculosis
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   Iranian J Publ Health, Vol. 41, No.11,Nov2012, pp.19-26  Original Article 19Available at: Predictors of Non-Uptake of Human Immunodeficiency VirusTesting by Tuberculosis Public Primary Patients in Three Districts,SouthAfrica *K Peltzer  1, 2   , G Mchunu  1   , B Tutshana  1   , P Naidoo  1, 3   , G Matseke  1   , J Louw  1  1.HIV/STI and TB (HAST) Research Programme, Human Sciences Research Council, Pretoria, Durban and Cape Town,South Africa 2.Dept. of Psychology, University of Limpopo,Turfloop, South Africa, 3Department of Psychology, University of the Western Cape, Cape Town, South Africa  *Corresponding Author: Email: (Received11Feb2012; accepted12Sep2012) Introduction South Africa has 0.7% of the worlds population,and 28% of the worlds population of HIV and TB co-infected individuals (1). It has beenestimated that there is approximately 60% of people with TB who are co-infected with HIV (2).Co-infected patients have almost double thechances of getting MDR-TB as well as XDR-TB. These patients also have a high mortality rate dueto co-infection with HIV (3). HIV testing among  TB patients provides access to the package of HIV treatment and care. The World HealthOrganization (4) has recently recommendedroutine HIV counselling and testing of all TBsuspects. In South Africa, provider-initiated HIV counselling and testing has been integrated intothe TB management strategy (3). According to the    AbstractBackground:  The acceptance of HIV testing among patients with tuberculosis (TB) is low in South Africa. The aimof this study was to assess the prevalence, associated factors and reasons ofnon-uptake of human immunodeficiency  virus (HIV) testingby tuberculosis public primary care patients in three districts, South Africa. Methods: In May-October 2011, this cross-sectional survey was conducted amongst 4726 TB patients across 42primary health care facilities in three districts in South Africa. All new TB and new retreatment patients (N=4726) were consecutively interviewed within one month of anti-tuberculosis treatment. The outcome was self-reported HIV testing after TB diagnosis, validated using clinic registers. Results:  Almost one in ten (9.6%) of the 4726 participants had not undergone HIV testing, with the most oftenoffered explanation being that they were not knowing where to get tested (21.3%), followed by believing not to haveor at risk for HIV (24.3%), emotional concerns (not ready for test: 13.2%; afraid to get to know: 12.1%; concerns overconfidentiality: 6.3%) and concerns about stigma (3.3%) and losing the job (2.0%). In multivariable analysis being male, severe psychological distress, having sex with someone HIV negative or unknown and frequency of sex withouta condom were associated with not having been tested for HIV. Conclusions:  The level of HIV testing among TB public primary care patients was suboptimal, as per policy allpatients should be tested. The South African Department of Health should continue to scale-up HIV testing and othercollaborative TB-HIV services at health facilities. Keywords: HIV testing, Predictors, Tuberculosis patients, South Africa   Peltzeretal.:Predictors of Non-Uptake of Human Immunodeficiency Virus …  Available at: African national tuberculosis managementguidelines, TB clients should be strongly advisedto have an HIV test; ideally the offer of an HIV test should take place soon after initiation of TBtreatment, as the morbidity and mortality of co-infected patients are the highest in the first twomonths of treatment (1). Previous studies in South Africa found that almost one third (32.5%) of tuberculosis (TB) patients reported that they hadnot undertaken HIV testing (5), in Ethiopia 29.4%(6) andeven a lower uptake of HIV testing among  TB patients was found in other studies (59%-65%) (7,8). A range of patient-level factors havebeen found to be associated with TB patients'non-uptake of HIV testing, including male sex (9),older age (8), lower education (6), being unemployed (7), employed (9), new treatment for TB (9), HIV risk behaviour (unprotected sex) (9),fear of stigmatization (6,10), fears of testing HIV-positive and death (5,11), perceived lack of confidentiality ofHIVtest results (8,10)and lack of knowledge about HIV counselling and testing procedures (7,8). The aim of this study was to assess the prevalence,associated factors and reasons ofnon-uptake of human immunodeficiency virus (HIV) testing by tuberculosis public primary carepatients in threedistricts, South Africa. Materials and Methods Sample and procedure   Three provinces, in South Africa, with the highest TB caseload were selected for inclusion in thestudy. One district in each province (N = 3) withthe highest TB caseloads were ultimately included. These districts were Siyanda in Northern CapeProvince, Nelson Mandela Metro in the EasternCape Province, and EThekwini in KwaZulu-NatalProvince. Within each of these three study districts 14 primary health care facilities wereselected on the basis of the highest TB caseloadsper clinic (N = 42). The type ofhealth facilities were primary health care clinics or community health centres. All new TB and new retreatmentpatients were consecutively interviewed withinone month of anti-tuberculosis treatment. Theinterview was conducted by trained externalresearchassistants for a period of 6 months in all42 clinics. A health care provider who identified anew TB treatment or retreatment patient (withinone month of treatment) and 18 years and aboveinformed the patient about the study and referredthe patient forparticipation if interested. Aresearch assistant asked for permission/consentfrom patients attending the primary care facility toparticipate in the screening interview. We have received ethical approval from theHuman Sciences Research Council ResearchEthics Committee (Protocol RECNo.1/16/02/11). The Department of Health inSouth Africa has also provided approval for thisstudy. Measure   A researcher-designed questionnaire was used torecord information on participants age, gender,educational level, marital status, income,employment status, dwelling characteristics andresidential status.Povertywas assessed with 5items on the availability or non-availability of shelter, fuel or electricity, clean water, food andcash income in the past week. Response optionsranged from 1=Not one day to 4=Every day of the week. Poverty was defined as higherscores on non-availability of essential items. Thetotal score ranged from 5 to 20, 5=being low, 6-12= medium and 13-20=high poverty. Cronbachalpha for this poverty index was 0.89 in thissample. TB treatment status and HIV statuswere assessedby self-report and from medical information. Those who got tested for HIV were asked forreasons to get tested and those who had not beentested were asked for reasons of not having beentested for HIV.Participants were asked, in general, would you say your health is: excellent, very good, good, fair orpoor? This measure was categorized based onparticipant response (very good = excellent/very good, good, and poor= fair/poor). The 10-item Alcohol Disorder Identification Test(AUDIT) (12) assessed the alcohol consumption   Iranian J Publ Health, Vol. 41, No.11,Nov2012, pp.19-26  21Available at: (3 items), symptoms of alcohol dependence(3 items), and problems associated with alcoholuse (4 items). Responses to items in the AUDIT were rated on a 4-point Likert scale from 0 to 4,for a maximum score of 40 points. Higher AUDIT scores indicate more severe levels of risk;scores 8 indicate a tendency to problematicdrinking (hazardous or harmful drinking) (12).Cronbach alpha for theAUDIT in this sample was 0.92, indicating excellent reliability. Two questions were asked about the use of tobacco products. 1) Do you currently use one ormore of the following tobacco products(cigarettes, snuff, chewing tobacco, cigars, etc.)?Responseoptions were yes or no. 2). In thepast month, how often have you used one ormore of the following tobacco products(cigarettes, snuff, chewing tobacco, cigars, etc.)?Response options were once or twice, weekly,almost daily and daily. The Kessler Psychological Distress Scale (K-10) was used to measure global psychological distress,including significant pathology which does notmeet formal criteria for a psychiatric illness (13,14). This scale measures the following symptoms overthe preceding 30 days by asking: In the past 30days, how often did you feel: nervous; so nervousthat nothing could calm you down; hopeless;restless or fidgety; so restless that you could notsit still; depressed; that everything was an effort;so sad that nothing could cheer you up; worthless;tired out for no good reason? The frequency  with which each of these items was experienced was recorded using a five-point Likert scaleranging from none of the time to all the time. This score was then summed with increasing scores reflecting an increasing degree of psychological distress. We examined the K-10scale using as a binary variable comparing scoresof 0-29 versus 30 or more (13,14). The internalreliability coefficient for the K-10 in this study  was alpha = 0.92.HIV risk behaviourwas assessed with thefollowing items: sexually active in the past 3months, unprotected last sex, the number sexoccasions with condom use in the past 3 months,the number of sex occasions without condom usein the past 3 months, andHIV status of a sexualpartner. Results Sample characteristics  Of the total sample (N=4935), 35 (0.7%) refusedto participate, so the final sample included 4900,54.5% men and 45.5% women, with a mean ageof 36.2 years (SD=11.5), range 18 to 93 years. Almost two-thirds of the participants (65.2%) were between 25 to 44 years old, the majority (72.7%) was never married, 27.7% had completedsecondary education, 17% scored high on thepoverty index, and only 24.2% had as a mainhousehold income a formal salary. Participantscharacteristics stratified by HIV test uptake arepresented in Table 1. Almost one in ten (9.6%) of the 4726 participants had not undergone HIV testing. Table 1: Sample characteristics of TB patients inthree different districts in South Africa   Tested for HIV (n=4273, 90.4%)n (%) 1 Not tested for HIV (n=453; 9.6%)n (%) 1  Age  (N=4837; 63 missing)18-2425-3435-4445or more561 (90.5)1643 (92.4)1148 (90.1)873 (87.5)59 (9.5)136 (7.6)126 (9.9)125(12.5) Gender  (N=4825, 75 missing)MaleFemale2227 (87.7)1981 (93.5)311 (12.3)138 (6.5)   Peltzeretal.:Predictors of Non-Uptake of Human Immunodeficiency Virus …  Available at:  Marital status  (N=4632, 268 missing)Not marriedMarried/cohabitating Separated/divorced/widowed2954 (91.0)881 (90.5)233 (86.0)291(9.0)92 (9.5)38 (14.0)  Education  (N=4818, 82 missing)Grade 7 or lessGrade 8-11Grade 12 or more1091 (88.9)3004 (90.9)124 (89.9)136 (11.1)299 (9.1)14 (10.1) Poverty index  (N=4620, 280 missing)Low MediumHigh1447 (91.8)1972 (90.4)637(87.0)130 (8.2)209 (9.6)95 (13.0) Residence  (N=4827, 73 missing)UrbanRuralInformal settlement2786 (89.5)793 (93.7)649 (90.1)327 (10.5)53 (6.3)71 (9.9) Perceived health status  (N=4833, 67 missing)Excellent/very goodGoodFair/poor764(87.0)1483 (91.1)1997 (91.5)114 (13.0)144 (8.9)186 (8.5) TB treatment status  (N=4835, 65 missing)New TBRetreatment1009 (92.0)3228 (89.9)363 (10.1)88 (8.0) Current tobacco use  (N=4735, 165 missing) YesNo1097 (87.4)3064 (91.7)158(12.6)278 (8.3) Hazardous or harmful alcohol use  (N=4808, 92 missing) YesNo984 (88.6)3271 (91.0)122 (11.4)325 (9.0)Severe psychological distress (N=4845, 55 missing) YesNo1017 (88.1)2988 (91.3)138 (11.9)283 (8.7) Sexually active in the past 3 months  (N=4585, 315 missing) YesNo2013 (88.8)2018 (62.1)255 (11.2)174 (7.9) Last sexual partner  (N=4453, 447 missing)HIV negative or unknownHIV positive2754 (87.3)1168 (98.9)402 (12.7)13 (1.1) Sex without condom use occasions (past 3 months) (N=2632)0-2 times3-2021-41+ times1387 (90.9)607 (86.7)257 (81.6)139 (9.1)93 (13.3)58 (18.4) Sex with condom use occasions (past 3 months) (N=2623)0-2 times3-2021-41+ times1059 (87.0)725(90.0)461 (90.0)158 (13.0)81 (10.0)51 (10.0) Unprotected last sex  (N=4287, 613 missing) YesNo2140 (93.4)1660 (88.0)152 (6.6)226 (12.0) 1 N do not add up to the total due to missing values   Table 1:  Cond…   Iranian J Publ Health, Vol. 41, No.11,Nov2012, pp.19-26  23Available at: HIV testingcharacteristics   Those who got tested for HIV gave as majorreasons to get tested I was feeling sick (50.6%)and I wanted to know my HIV status (33%)(Table 2). Most had been tested in a public healthfacility (clinic or doctor 68.3% and hospital20.5%), followed by private health facility (hospital 4.8% and private clinic or doctor 3.5%),HIV testing centre 2.0%, youth centre or loveLifeclinic 0.5% and in the workplace 0.2%. The mostrecent HIV test had been for most (76.3%) less ayear ago, 11.2% between one to two years ago and12.4% two or more years ago.Major reasons not to get tested for HIV was notknowing where to get tested (21.3%), followed by believing not to have or at risk for HIV (24.3%),emotional concerns (not ready for the test: 13.2%;afraid to get to know: 12.1%; concerns overconfidentiality: 6.3%) and concerns about stigma(3.3%) and losing the job (2.0%) (Table 3). Themajority (77.0%) indicated that they wanted toknow their HIV status, 8% were unsure and 15%did not want to know if they were HIV positive ornegative. Predictors of not testing for HIV  Univariate analyses found that being male, being separated, divorced or widowed, high poverty,urban residence, excellent or very health status,being on TB retreatment, substance use(alcohol,tobacco), severe psychological distress and being sexually active (without a condom) wereassociated with Not tested for HIV, while inmultivariable analysis being male, severepsychological distress, having sex with someoneHIV negative or unknown and frequency of sex without a condom were retained in the analysis(Table 4). Table 2: Main reason for going for your mostrecent HIV test of TB patients   n% I was feeling sick221450.6I wanted to know my HIV status144433.0I wasinstructed by a health worker(nurse/doctor)2926.7I was pregnant1463.3My partner asked me to go fortesting 1182.7My employer requested it631.4I wanted to start a new sexualrelationship41.9 Workplace campaign18.4I wanted to getmarried14.3Other12.3I applied for a loan7.2I applied for an insurance policy6.1 Table 3: Main reason for not going for an HIV test of TB patients n% I do not know where to get tested11821.3I do not think that I have HIV9016.3Iam not ready to have an HIV test7313.2I was afraid to find out that I might beHIV positive6712.1I trust my partner5910.7I am not at risk for HIV448.0I was concerned about confidentiality356.3I havent got around to it203.6I wasconcerned about stigma,discrimination or rejection183.3Other132.4I was concerned about losing my job112.0I am concerned about the standard of service5.9 Table 4: Predictors of not tested for HIV of TB patients in three different districts in South Africa Crude OR (95% CI) a  Adjusted OR (95% CI) a,b  Age18-2425-3435-4445or more1.000.79 (0.57-1.08)1.04 (0.75-1.45)1.36 (0.98-1.89)---
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