Research consultancy
Factors Influencing the Utilization of HIV Voluntary Counselling and Testing Services among Youth in Bukasa Community.
1.1 Introduction
Voluntary counselling and testing (VCT) is one of the key strategies used in the fight against Human Immunodeficiency Virus (HIV)/ Acquired Immunodeficiency Syndrome (AIDS) in Uganda and the world at large. Globally, about 37.9 million people are living with HIV of which 68% are in Africa. East Africa has 20.6 million people living with HIV. Of the 1.7 million new HIV infections in the world, 800,000 were in Sub Saharan Africa (SSA) (World Health Organisation [WHO], 2018).
Uganda was one of the first countries to take on VCT in a bid to curb the HIV epidemic. However, people especially in rural areas including the youths have not fully embraced this service (Mafigiri, 2017). This study uncovered factors behind the low uptake of VCT services among youths in Bukasa, a rural community in Wakiso district.
Discussed in this paper is the background, problem statement, purpose, specific objectives, research questions and significance of the research to the nursing profession.
1.2 Background
The first HIV/AIDS case in Uganda was in 1982 in Kasensero, a fishing village located in Rakai district. It later spread to neighboring areas then to the urban areas. There was a high prevalence rate of HIV/AIDS of 18 percent in 1990’s but it dropped to 6.0 percent in 2006 owing to behavioral changes that the government had implemented ((Mugisha, van Rensburg, & Potgieter, 2010).In 2013, 35 million people were living with HIV globally and 24.7 million of those were in SSA. Globally, 1.6 million people have died due to HIV/AIDS related illnesses of which in 2012 75 percent were in SSA. This left a financial burden on these resource-limited nations (Lubogo, 2015).
HIV is an infection of the immune system and it mainly attacks the CD4 cells and replicates within the host cell leading to crippling of the immune system of the infected person. This leaves the person vulnerable to infections, which later leads to a syndrome known as AIDS. There are two main strains of HIV, HIV-1 and HIV-2. HIV-1 is the most common in Uganda (WHO, 2018).
HIV counselling and Testing (HCT) is a service provided to someone with the intention to reveal their HIV status which can be either negative, meaning the person is HIV free or positive, meaning the person has HIV. Voluntary Counselling and Testing (VCT) is a key component of HCT where an individual willingly seeks HCT services in order to know their HIV status (Wanyenze et al., 2013).
There are two main ways of providing VCT. There is the traditional form of VCT, which is client–initiated. Here a client requests for an HIV test from the health care provider. The second is Provider initiated testing and counseling (PITC) in which a health care provider recommends VCT to the client. This takes place in a health care setting. The main aim of PITC is to diagnose the client by either confirming or ruling out HIV infection. Routine counselling and testing (RCT) is the provision of HCT services to a client regardless of their present health complaints, in this all clients who come to the health facility have an HIV test. It’s aim is to increase the uptake of HIV services like PMTCT (Prevention of Mother to Child Transmission).
Consent, counseling and confidentiality are the three main components of VCT. Every health care provider must obtain written permission from the client before conducting the HIV test. The client must receive pre and post-test counseling in preparation for the HIV test results. This tackles what the client will do if the results are positive or even when they are negative, behavioral changes like practicing safe sex; faithfulness and reduction of risky behavior like drug use are emphasized. The client must trust that HIV test results are confidential and not for public view (Kitara, Amone, & Okello, 2012).
A youth is a young person between 15-35 years of age (African Youth Charter, 2006). Youth constitute about 77 percent of Uganda’s population. 7.3% of Ugandans are living with HIV of which 3.7% are youth. Globally, there were 4.2million youths living with HIV of which SSA is home to 72% of them. The youth are under the vulnerable and high-risk groups for HIV infection both globally and in Uganda because of their risky sexual behavior including low condom use, multiple sexual partners and limited knowledge about HIV/AIDS (Strauss, Rhodes, & George, 2015).
These groups are key in HIV prevention and transmission and yet VCT services are not fully utilized by the youth.. For this reason, youth are a focus in the control of the spread of HIV. Most studies conducted in Uganda have focused on the risky sexual behavior among youths. This has left a gap on data concerning VCT uptake among youths (Mafigiri et al., 2017). However, some research shows that there is low VCT uptake among youths because of fear of positive HIV results, fear of stigma from peers and family members and parental view of seeking VCT services as a sign of promiscuity (Sam-Agudu, Folayan, & Ezeanolue, 2016).
Uganda was one of the first African countries to implement VCT and by 2005; it was available in all districts. Still, due to low uptake of VCT services Uganda introduced home–based testing where clients receive VCT from their homes (Wanyenze et al., 2013).
It is against the fact that the youth have an HIV prevalence rate of 3.7% and a low VCT uptake (Mafigiri et al., 2017) and (Sam-Agudu et al., 2016) that this study intends to explore the factors behind the low VCT uptake among youths since they are more than 50% of Uganda’s population.
1.3 Problem statement
VCT is a main strategy put in place to curb the HIV epidemic globally. Research shows that youths are not fully accessing this service. Globally, 37.9 million people are living with HIV of which 68% are living in Africa. In addition, 72% of the infected people in Africa live in SSA. About 20.6 million people are living with HIV in East Africa (WHO, 2018).
Globally, 4.2 million youths were living with HIV of which 1.6 million were in Uganda in the year 2013. There is evidence that there is low uptake of VCT services by youths both globally and in Uganda (Mafigiri, 2017). This puts HIV reduction goals at stake since more than 75% of Uganda’s population is made of youths (Lubogo, Ddamulira, Tweheyo, & Wamani, 2015).
Although there is limited information particular to Bukasa, some of the reasons for low VCT uptake among youths in Uganda are; poor attitude and customer care among health workers and need for parental consent in the process of accessing VCT services. In addition to the above, fear of being diagnosed with HIV, which comes with stigma and discrimination from peers and family members also reduces VCT uptake among youths .
1.4 Purpose/objectives
The purpose for this study is to identify the factors influencing VCT uptake among youths in Bukasa community.
1.5 Specific objectives
The specific objectives of the study are three and these include;
- To asseess the knowledge and attitude of youth towards VCT services in Bukasa community.
- To identify the factors favoring the utilization of VCT services by youths in Bukasa community.
- To identify the barriers to access to VCT services by youth in Bukasa community.
1.6 Research questions
What are the factors influencing the utilization of VCT services among youth in Bukasa community?
1.7 Conceptual framework
This study seeks to address the factors influencing the utilization of VCT services among youths in Bukasa community. Bandura’s social cognitive theory of human behavior has been adopted for this study. In this model, three dynamics are responsible for the utilization of health care services including VCT services. These are; behavior, beliefs (personal) and environmental factors.
Behavioral factors; self-efficacy enables one to know that they can test for HIV. Skills; ability to correctly use a condom and also seek VCT services and skills for negotiation which enables one to talk their prospective sexual partner into an HIV test and safe sex practices before a sexual encounter. Practice; which entails consistent correct condom use and either faithfulness in a relationship or abstinence from sex greatly determine one’s decision to seek VCT services because they form a basis for expected HIV results.
Environmental factors including social norms may hinder younger youths from seeking VCT services. This is because many people think youths who seek VCT services are promiscuous. In addition, access of VCT services in the community meaning availability and cost affects their uptake by youths. The influence of others like advice from peers and family can determine whether one goes for an HIV test or not. Youths stated that home-based testing is better because of a supportive environment of family members than at school where peers may speculate about your results basing on the mood you leave the counselling room (Strauss et al., 2015).
In addition, some noted that the health facility environment is not so favorable because of separation of people who seek VCT services from those that seek general health services, which notifies all hospital clients your intention. In environments like school, some feel that the quality of privacy and confidentiality might be compromised leading to disclosure of their HIV status (Strauss et al., 2015).
The personal factors associated with VCT utilization include the belief that testing HIV positive means the end of one’s life. Furthermore, some youths believe that a positive HIV diagnosis will reduce their level of joy and happiness leading to misery.
Bandura’s social cognitive theory of 1986.
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1.8 Significance
This study will provide information on the factors influencing the uptake of VCT among youth in Bukasa community. These results may be of relevance to health and nursing in that they may identify deterrents to VCT uptake among youths and modify service provision to suit youths.
The results of the study may also enable health workers in Bukasa to develop strategies to increase VCT uptake, which will reduce on HIV infections and increase HCT service uptake in Uganda at large, which will reduce on the workload and the financial burden of HIV on the health sector.
This study may also provide health workers in Uganda with reasons for low up of VCT services among youths.
2.0 Chapter 2: Literature Review
This chapter will entail review of literature regarding knowledge and attitude of VCT services among youths, reasons for taking up VCT services and the barriers to VCT services among youth.
2.1 Knowledge and attitude regarding VCT services among youth
Most research suggests that despite the high knowledge of VCT services among youth, many do not utilize it. In a study conducted among tertiary students in Nigeria to access the knowledge and their willingness to pay for VCT services, 64 percent were aware of VCT services but only 19 percent of them had utilized the service meaning 81% of the youth did not utilize the service. Also,76% of youths viewed VCT as a source of crucial information regarding HIV prevention and control (Uzochukwu, Uguru, Ezeoke, Onwujekwe, & Sibeudu, 2011).
In agreement with the above research, a study conducted among youth in Kenya found high knowledge levels and positive attitude among the participants towards VCT services but with underutilization of the service. Only 52% of the participants had tested for HIV. The main source of VCT information was media (Ndwiga & Omwono, 2014).
In addition, a cross sectional study among school students in Arusha, Tanzania found that much as 93.5% of the research participants were aware of VCT services and 79.1% of them had good knowledge regarding VCT, only 29.3% of the participants had ever had VCT although 75.9 % of them had positive attitude towards VCT (Sanga, Kapanda, Msuya, & Mwangi, 2015).
Kitara, Amone, and Okello (2012) made similar findings among youth in Gulu, Uganda where 93% of youth had knowledge about VCT, 84.9% of the youth would encourage their associates to have an HIV test but only 36.1% had an HIV test. These youth obtained information regarding VCT from media (mainly radio stations), health workers and other sources like social gatherings and VCT related posters in a ratio of (26.9% : 41.3% : 19.2%) respectively. The aim of this study was to access the knowledge and misconceptions about HIV HCT among the post-conflict youth in Gulu district.
In contrast to the above findings, a study conducted in South Africa among students found that many of the youth had a negative attitude towards VCT and many did not take HIV tests regardless of their vast knowledge about VCT (Makhubele, Dhlamini, & Khoza, 2015). In addition Amu (2014) set out to discover the knowledge and attitude amongst youth that served on Nigeria’s National Youth Service Corps and found that although 58% had a positive attitude regarding VCT, 42% had a negative attitude towards VCT which was a very big number of youths in comparison to the research analyzed above.
2.2 Factors favoring the utilization of VCT services among youth.
A research aimed at assessing factors influencing VCT uptake among youth in Zanzibar found that youth undergo VCT because of different reasons like, job requirement where the employer requires them to present their HIV results like during military recruitment. At times youth take on VCT services as a requirement by health insurance companies. Sometimes youth test for HIV as a recommendation by a health care provider like during pregnancy, as a way of diagnosing disease especially when they present with HIV symptoms, when planning to get married and when undergoing medical procedures like blood and organ donation. In addition, the same research discovered that some youths undergo VCT because of uncertainty of their HIV status especially after unprotected sex, injectable drug use, distrust of sexual partner and self-perceived HIV risk (Moh’d, 2015).
The research conducted by Dirar, Mengiste, Kedir, and Godana (2013) with the aim of finding out factors contributing to VCT uptake among college students at an Ethiopian university concluded that majority of the youths (89.9%) underwent VCT to know their sero status and 3.8% got tested because they were planning to get married.
In addition, some youth take an HIV test out of inquisitiveness just to know how the whole process goes and know their HIV status. Some of them aim at accessing early treatment in case they are infected and others desire to use VCT results as a basis for the measurement of the extent of faithfulness of their sexual partners. These were results of a research conducted in Mount Kenya university whose aim was to make an analysis on the uptake of VCT services among the university students (Museve, Gongera, George, & Loum, 2013).
2.3 Barriers to access to VCT services by youth
The low utilization of VCT services among youths is due to several factors. In Nigeria, Yahaya, Jimoh, and Balogun (2010) found that poverty which leads to inability of some youths to pay user fee for VCT services as charged by service providers hinders them to access VCT services. However, Uzochukwu et al. (2011) found that 50% of youth were willing to pay for VCT services in facilities where it was not free although 67.6% of youth felt HIV counseling and testing should be free.
In addition, fear of stigma and discrimination by peers and the community discourages some youth from taking up VCT because the community assumes that whoever takes an HIV test is infected (Mugisha, van Rensburg, & Potgieter, 2010; Sanga et al., 2015).
Knowledge deficit regarding the VCT procedure discourages some youths from testing for HIV. These findings are consistent with those of Moh’d (2015) who in addition attributed low VCT uptake due to perceptions by the youth that HIV results were inaccurate and not confidential, impolite service providers, lack of youth friendly services and long waiting hours at the health facilities.
According to Ndwiga and Omwono (2014) there are limited resources to provide VCT to the youth. Some of these are in form of personnel like professional counselors that leads to poor quality of services delivered. Adding to the above, youth are fearful of positive HIV test results and dread meeting their parents at the testing centers since even younger youth have to access VCT services together with adults (Fikadie, Bedimo, & Alamrew, 2014; Moh’d, 2015; Ndwiga & Omwono, 2014). This is contrary to the findings of (Gwandure, Ross, Dhai, & Gardner, 2013) who found that majority of parents are in support of youth accessing VCT as a way of combating the HIV/AIDS although they desired that all stake holders are involved in the planning process.
Adding to the above barriers, lack of proper policies regarding consent for VCT services by youths especially those below eighteen years is one of the barriers that policy makers need to address in order to improve and increase the number of youth utilizing VCT services (Govindasamy et al., 2015; Ndwiga & Omwono, 2014).
Although many youth across the globe have good knowledge regarding VCT services, there is underutilization of these services owing to the barriers identified above. The barriers specific to youth in Bukasa community are unknown therefore, this study aims at identifying the facilitators and barriers to utilization of VCT services in Bukasa village.
