Research Article - (2017) Volume 4, Issue 2
Tadele Lamore, Marelign Tilahun and Wanzahun Godana*
Department of Public Health, Arba Minch University
*Corresponding Author:
Wanzahun Godana
Lecturer, Department of Public Health,
Head, Research Coordination Office, College
of Medicine and Health Sciences, Arba
Minch University, Ethiopia.
Tel: +251 46 881 4986
E-mail: wanzanati2011@gmail.com
Received date: February 06, 2017, Accepted date: April 03, 2017, Published date: April 10, 2017
Citation: Lamore T, Tilahun M, Godana W. Determinants for Refusal of Provider Initiated HIV Testing and Counseling among Adult OPD Clients in Kachabira District Health Centers, South Ethiopia: Institution based Unmatched Case Control Study. Health Syst Policy Res. 2017, 4:2. doi: 10.21767/2254-9137.100072
Background: Provider initiated HIV testing and counseling serve as a gateway to HIV prevention, early access to treatment, Care and Support interventions. However, PITC refusal rate tends to be high in OPD setting compared to other clinical service delivery areas. The objective of this study was to assess determinants for refusal of PITC among clients attending adult OPD services in Kachabira District Health Centers, 2015.
Method: Institution based unmatched case control study design was conducted from Mar 25 to Apr 24/2015. A total of 503 OPD clients (116 cases and 387 controls) were enrolled from five health centers. Cases were OPD clients who refused PITC and controls were OPD clients who accepted PITC. Data were collected by using face to face interview and entered by EPi info version 6 and transported to SPSS version 20 for analysis. Backward Stepwise LR method was used to analyze the data and Strength of the association was assessed using odds ratio with 95% CI.
Results: only 25.3% of clients were ever tested through health care provider initiation approach. Sex, poor access to PITC information from health workers, lack of comprehensive knowledge and self-risk perception to HIV infection were found to be statistically significant predictors for refusal of PITC with AOR (95%CI) of 3.1(1.55-6.32), 3.2(1.59-6.58), 2.2(1.16-4.50) and 3.5(1.46-8.26) respectively. Moreover, thinking self not at risk for HIV infection (77.6%), lack of interest and unpreparedness (67%), ever tested before (66.4%) and no sure of confidentiality (16.4%) were the main reasons for refusal of PITC.
Conclusion: Generally, the number of clients ever tested by provider initiation was low. Lack of comprehensive knowledge and risk perception to HIV infection, poor access to PITC information from health workers are main factors for refusal of PITC service.
Keywords
Refusal of PITC; OPD clients; Voluntary HIV testin, Kachabira district.
Introduction
Nowadays the HIV pandemic remains one of the world’s most significant public health problems, particularly in sub-Saharan countries. In 2013, there were an estimated 35 million people living with HIV/AIDS worldwide, with more than two-thirds (24.7 million) of all age group of the world population living in sub Saharan Africa [1,2].
To respond the epidemic, client-initiated voluntary counseling and testing service was introduced as a key component of HIV prevention programs. However, relying on only this traditional model of client-initiated (VCT) approach often faced low uptake of HIV testing, late diagnosis and low ART coverage particularly in generalized epidemic regions [3,4].
Therefore, to overcome these challenges and achieve universal access targets; WHO, UNAIDS, and CDC introduced PITC as an efficient and cost-effective HIV testing approach to rapidly and massively increase HIV testing rates [5]. Health facilities represent a key point of contact of patients with suspected and unsuspected HIV infection [6]. Thus, health care providers should recommend PITC to all patients in every health-care contact seen in all health facilities regardless of whether the patient shows clinical signs and symptoms of underlying HIV infection in generalized epidemic situation unless clients refuse the test [5,7,8]. However, evidence from generalized epidemic settings suggests that routine offer of provider initiated HIV testing and counseling has not been a priority, as the result PITC coverage is often low [6].
Globally, 35 million people were living with HIV; about 2.1 million people were newly infected and 1.5 million AIDS related deaths at the end of 2013 [1]. Of the 35 million people living with HIV in the world, 19 million have never been tested for HIV, and therefore are not in the position to know their HIV status [2]. Furthermore, the current estimates indicate that more than 60% of people living with HIV in developing countries are unaware of their infection and so cannot benefit from earlier treatment and care services that substantially declines morbidity and mortality [9].
Sub-Saharan Africa remains the hardest-hit region by epidemic and continues to bear a disproportionate share of the global HIV burden and accounting for approximately 71% of the world’s new HIV infection with an estimated adult (15-49 years) HIV prevalence rate of 4.7 [10]. Ten countries including Ethiopia, account for 81% of all people living with HIV in the region. Ethiopia is one of the sub-Saharan countries most affected by HIV/AIDS with an estimated adult prevalence rate of 1.2 [2]. The HIV estimates of Ethiopia showed that 769,602 people currently living with HIV/ AIDS, from this, 591,146 of HIV positive cases were found in the age range of above 15 years. New HIV infections and annual AIDS deaths were found to be 11,264 and 26,019 respectively in this age group [11].
The epidemic of HIV/AIDS affects economically active segment of population, 15-49 years old, are highly affected by HIV/AIDS, it results in considerable productivity loss due to persistent illnesses and deaths with loss of skilled labor force [11,12]. The HIV epidemic in Ethiopia is mainly heterogeneous and affecting almost all segments of population groups in all geographic areas of the country, including the remote areas [13]. The spread of the epidemic in the country is facilitated by different factors like diversified socio-cultural norms, poverty, expansion of small town which act as the bridge to spread HIV infection to rural communities, increased migration of people from rural to urban, low level of comprehensive knowledge about HIV/AIDS and inaccessible and inadequate basic HIV service coverage could be cited as some of the drivers of the epidemic [11,14].
Despite the fact that the Government of Ethiopia adopted a comprehensive and encouraging national HIV/AIDS policy to combat the epidemic; still there are challenges that the government faced to achieve universal access to HIV prevention, treatment, care and support services [15]. Moreover, to achieve global vision of ambitious new targets of zero new HIV infections, zero discrimination and zero AIDS-related deaths; much effort will be needed to expand primary prevention activities to reduce new infections among sexually active young and adult population significantly at grass root level [16,17].
Although HIV testing and counseling uptakes has improved in Ethiopia from time to time, the majority of people living with HIV remain unaware of their HIV status, as the result significant proportion of people living with HIV remain undiagnosed until they become symptomatic, thus presenting late for treatment [7,18]. Therefore, lack of knowledge of once sero-status is a major challenge to attain the goal of universal access to prevention and treatment [3, 4]. According to the recent EDHS report, coverage of HIV testing and counseling was only 36% for women and 38% for men [18]. Even though the number of facilities providing HCT services increased though time, only 54.9% and 57.0% of pregnant women were counseled and tested for HIV in 2013 and 2014 respectively [19,20].
The use of routine HIV testing and counseling services is the essential first step towards ensuring access to interventions for prevention, early access to treatment and care of HIV/ AIDS [7]. However, particularly in outpatient settings there are various factors enabling the refusal of HIV testing and counseling including socio-demographic factors, insufficient awareness of HIV prevention, transmission and testing benefits, concerns about stigma and discrimination, low perception of HIV risk, fear of the test and the consequences of a positive test result and concerning about confidentiality [21-23].
Refusal rates of provider initiated HIV testing and counseling tend to be high in OPD settings compared to other service provision settings like TB, ANC and inpatient clinics [24]. There are different studies were conducted in Africa on acceptance of PITC and the results were poor [25,26]. In Ethiopia, few Studies done among OPD clients on acceptance of PITC found that the refusal rate was high [21,23].
Good knowledge of HIV/AIDS was related to PITC uptake. Studies in SSA on factors enabling and deterring uptake of HIV testing found that low knowledge about HIV transmission and prevention was associated with low uptake of HIV testing and counseling [27-31]. Low risk perception to HIV infection has been frequently cited as one of the factors hindering HIV prevention behavioral changes. Individuals who perceived their risk of HIV infection as low are likely to engage in high-risk behaviors, and do not experience the need for HIV testing and counseling [32,33]. And also lack of the risk perception to HIV infection was found to be strong determinant factor for low acceptance of available HIV testing and counseling services [34-37].
Studies conducted in SNNPR showed that participants who had not got HIV testing and counseling information from health facilities had siginficant association with low utilization of HIV testing [37-39]. Lack of risk perception, fear of positive result due to stigma and discrimination and partner trust were the commonest reasons for refusal of PITC [40-44].
Therefore, the aim of this study was to assess the determinants for refusal of PITC among clients attending adult OPD services of Kachabira district health centers of Southern Ethiopia.
Methods and Materials
Study setting and population
Institution-based, unmatched case control study was conducted among adult OPD clients from March 25 to April 24/ 2015. Kachebira District is located in Kambata-Tambaro zone which is in the middle of the SNNPR and it is 372 km away from Addis Ababa. According to the 2007 Ethiopian census report, the population of Kachebira District was projected to be 149,296, out of which,72065 were adult populations (15- 49 years). Administratively there are 23 kebeles in the study area. Five health centers providing preventive and curative services including HIV testing and counseling services and other service packages for the catchment population. Potential health service coverage reached 83% with OPD attendance per capita was 0.4. Source Population of the study all outpatient department clients (15-49 years) who were visiting the health centers of the district were the target of this study and the Study population were all OPD clients (15-49 years) who were visiting the health centers during the data collection period were the study population.
Inclusion criteria and exclusion criteria
All clients (15-49 years) with medical conditions, both male and female were considered for this study. This age group is sexually active and highly vulnerable to HIV epidemic than other age groups and also the prevalence of HIV was high among this age group. Those patients, who were seriously ill/ need urgent medical help, could not talk or listen; Clients living with HIV and Pregnant mothers were excluded.
Sample size and sampling procedures
The following parameters were used to calculate sample size: 95% confidence level, 80% power, case to control ration of 1:3, and the proportion of prior HIV testing exposure among cases (P1=15.3%) and proportion of prior HIV testing exposure among controls (P2=27.3%) as shown in the table blow. P1 and P2 were taken from similar study [44]. In order to increase the precision by reducing the sampling error an additional 5 percent was added for non-response. By using Epi- info the maximum sample size required were 530 clients. The total sample size was proportionally allocated to the five health centers based on the average monthly client flow by considering one year data from monthly report. Cases and controls who met the inclusion criteria were consecutively interviewed during study period until the required sample size was obtained.
Variables of the study
The Independent variables: Socio-demographic characteristics (Age, sex, marital status, occupation, religion, residence, educational status), Comprehensive knowledge on HIV/AIDS prevention and transmission, HIV risk-perception, source of PITC information, Knowledge on existence of PITC services nearby health facilities, Knowledge on benefit of PITC, Pervious HIV testing experience, Reason for refusal of PITC and the Dependent Variable was Refusal of provider initiated HIV testing and counseling.
Operational definitions
i. Non-acceptors (cases): Were study participants attending adult OPD services in five health centers that have been offered an HIV test by health care providers and refused HIV testing and counseling, between the ages of 15 to 49 years during the current OPD visit from March 25 to April 24/ 2015.
ii. Acceptors (controls): were study participants attending adult OPD services in five health centers that have been offered an HIV test by health care providers and accepted HIV testing and counseling, between the ages of 15 to 49 years during the current OPD visit from March 25 to April 24/ 2015.
Data collection tool and procedures
Structured, pre-tested and closed-ended interviewer administered questionnaire was used to collect the data. The questionnaire was prepared in English language and translated in to Amharic language for data collection and then back to English language. Two days training was given for five diploma nurse data collectors under close supervision. Trained health workers on PITC supported the data collection process by identifying and referring acceptors and refusals to data collectors by using codes for interview. The interview would be administered in the particular health center after the client completed medical care and a confidential client exit interview was conducted between the trained data collectors and clients. At the end of each day, the questionnaires were cross checked for completeness and accuracy by supervisors and investigator.
Data quality management
To assure the quality of data, the following activities were accomplished:-
The questionnaire was Pre-tested, Data collection instruments were properly prepared and training was given for five data collectors and supervisors before starting data collection.
Data processing and analysis
The data was entered by Epi info version 6 and transported to SPSS statistical package version 20 for analysis. Percentages, cross-tabulations and summary statistics were done to describe the explanatory variables. Bivariate logistic regression analysis (Backward Stepwise LR method) was done between each of the explanatory variables and the outcome variable. Variables that was found to be statistically significant in the bivariate analysis (p<0.25) was assessed for multicolinearity. Finally multivariate logistic regression analysis was performed to identify the independent contribution of multiple explanatory variables on an outcome variable and model fitness was checked by using Hosmer-lemeshow goodness-of-fit. The odds ratio, 95% confidence limits and p-Value were used to assess the strength of association between independent variables and outcome variable.
Ethical Consideration
Ethical clearance was obtained from the research ethics committee of College of medicine and Health Sciences, Arbaminch University. The head of Kachabira District health office and then the head of each of the five health centers were asked for permission. The aim of the study was clarified to the client to obtain verbal consent and to assure confidentiality, interview was carried out privately. The right of the study subject not to participate or withdraw from the study was respected.
Results
Socio-demographic characteristics of the study subjects
Out of total 530 clients (132 cases and 398 controls) requested for interview, 506 clients (119 cases and 387 controls) aged between 15 to 49 years were interviewed with response rate of 96% (90% for cases and 97.2% for controls). The mean age of the study participants was 29.1 years with SD of ±7.7 and 31 (+8.2 SD) years for cases and 28 (+7.4 SD) years for controls. A large percentage of the respondents, 43 (37%) cases and 191(49.4%) controls were in the age categories of 35–44 and 25-34 years respectively. Majority of cases, 90(77.6%) and controls, 247 (63.8%) were males and females respectively. About 92 (79.3%) of cases and 217(56%) controls were from rural areas. This study also found that large proportions of cases (87%) and controls (85.3%) had formal education. Majority of the participants were married 334(66.4%), house wife 161(32%), followers of protestant Christianity 370 (73.6%) and Kambata ethnic group 410 (82%) [Table 1].
| Variables | Cases (n=116) | Controls (n= 387) | Total n |
| n (%) | n (%) | ||
| Age (year) | |||
| 15-24 | 28(24.1) | 125(32.3) | 153(30.4) |
| 25-34 | 41(35.3) | 191(49.4) | 232(46.1) |
| 35-44 | 43(37.1) | 52(13.4) | 95(18.9) |
| ≥ 45 | 4(3.5) | 19(4.9) | 23(4.6) |
| Sex | |||
| Male | 90(77.6) | 140(36.2) | 230(45.7) |
| Female | 26(22.4) | 247(63.8) | |
| Residence | |||
| Rural | 92(79.3) | 217(56) | 309(61.4) |
| Urban | 24(20.7) | 170(44) | 194(38.6) |
| Religion | |||
| Protestant | 92(79) | 278(71.8) | 370(73.6) |
| Orthodox | 10(9) | 61(15.8) | 71(14.1) |
| Catholic | 14(12) | 48(12.4) | 62(12.3) |
| Marital status | |||
| Married | 86(74) | 248 (64.1) | 334(66.4) |
| Single | 25(21.6) | 118(30.5) | 143(28.4) |
| Others* | 5 (4.4) | 21(5.4) | 26(5.2) |
| Ethnicity | |||
| Kambata | 101(87) | 309(80) | 410(82) |
| Hadiya | 6(5.2) | 45(12) | 51(10) |
| Others** | 9 (7.8) | 33(8) | 42(8) |
| Formal education | |||
| No | 15(13) | 57(14.7) | 72(14.3) |
| Yes | 101(87) | 330(85.3) | 431(85.7) |
| Occupation | |||
| Employed | 104(90) | 342(88.4) | 446(88.7) |
| Non-employed | 12(10) | 45(11.6) | 57(11.3) |
*widowed and divorced, ** Wolayta, Amhara&Gurage
Table 1: Socio-demographic characteristics of adult OPD clients in Kachebira District health centers from March to April, 2015 (n=503).
HIV/AIDS and PITC related knowledge of clients by PITC refusal status
Regarding on clients’ prior HIV testing experience, 86(74%) cases and 309(80%) of controls had previously been tested for HIV. Among those patients who ever tested for HIV, 100(25.3%) clients were ever tested through provider initiation method (16.3% refusals and 27.8% acceptors) while the majority of the patients, 370(93.7%) were ever tested through VCT approach (97.7% cases and 92.6% controls). Number of respondents who have been tested for HIV during the last 12 months and who know their test results were 10 (11.6%) and 116 (37.5%) refusals and acceptors respectively. Out of all ever tested clients, 173(43.8%) of clients were tested only once (73% cases and 35.6% controls) [Table 3].
| Variables | case (n=116) | control (n=387) | Total n (%) |
| Heard of HIV/AIDS | 116(100) | 387(100) | 503(100) |
| Have comprehensive knowledge on HIV/AIDS | |||
| Yes | 60(51.7) | 274(70.8) | 334(66.4) |
| No | 56(48.3) | 113(29.2) | 169(33.6) |
| Risk perception on HIV/AIDS (487) | |||
| Yes | 19(16.8) | 101(27) | 120(24.6) |
| No | 94(83.2) | 273(73) | 367(75.4) |
| Heard about PITC | |||
| Yes | 97(84) | 333(86) | 430(85.5) |
| No | 19(16) | 54(14) | 73(14.5) |
| Source of PITC information (430) | |||
| Health workers | 47(48.5) | 261(78.4) | 308(71.6) |
| Mass media | 52(53.6) | 87(26) | 139(32.3) |
| Friends and family members | 27(27.8) | 43(13) | 70(16.3) |
| Others | 3(3.1) | 12(3.6) | 15(3.5) |
| Know existence of PITC service | |||
| in nearby HFsYes | 84(86.6) | 296(89) | 380(88.4) |
| No | 13(13.4) | 37(11) | 50(11.6) |
| Awareness on benefit of PITC | |||
| Yes | 76(78.4) | 271(81.4) | 347(80.7) |
| No | 21(21.6) | 62(18.6) | 83(19.3) |
Others= workplace meeting (main streaming), School, neighbors, from community Abbreviation: HFs, health facilities
Table 2: HIV/AIDS and PITC related knowledge by refusal of provider initiated HIV testing and counseling status among OPD clients in five health centers of kachabira district, SNNPR, 2015.
| Variables | Case (n=116) | Control(n=387) | Total n (%) | |
| n (%) | n(%) | |||
| Ever had HIV test before? | ||||
| Yes | 86(74) | 309(80) | 395(78.5) | |
| No | 30(26) | 78(20) | 108(21.5) | |
| Ever initiated by Heath care provider (n=395) | ||||
| Yes | 14(16.3) | 86(27.8) | 100(25.3) | |
| No | 72(83.7) | 223(72.2) | 295(74.7) | |
| Ever initiated voluntarily | ||||
| Yes | 84(97.7) | 286(92.6) | 370(93.7) | |
| No | 2(2.3) | 23(7.4) | 25(6.3) | |
| The most recent HIV test | ||||
| 3-12 months | 11(12.8) | 123(40) | 134(34) | |
| More than 12 months | 75(87.2) | 186(60) | 261(66) | |
| Know the result of the most recent test | ||||
| Yes | 84(97.7) | 282(91.3) q | 366(93) | |
| No | 2(2.3) | 27(8.7) | 29(7) | |
| Tested and know results during last 12 months | ||||
| Yes | 10(11.6) | 116 (37.5) | 126 (32) | |
| No | 76(88.4) | 193(62.5) | 269(68) | |
| Number of HIV testing | ||||
| Once | 63(73) | 110(35.6) | 173(43.8) | |
| More than once | 23(27) | 199(64.4) | 222(56.2) | |
Table 3: HIV testing and counseling practices by PITC refusal status among OPD clients in Kachabira district, southern region, Apr 2015.
The reasons for refusal of PITC in the current OPD visit
The most commonly cited reasons for refusal of PITC among cases were thinking self not at risk for HIV infection 90 (77.6%), lack of interest and unpreparedness 78 (67%) and ever tested before 77 (66.4%), not sure of confidentiality, believing partner and fear of stigma.
Determinant factors associated with refusal of PITC among OPD attendees
From all the socio-demographic explanatory variables considered in this study, being male was independently and significantly associated with refusal of PITC after controlling the effect of other explanatory variables. The odds of refusal of PITC among males were 3.1 times more than those of females, AOR=3.1 (95%CI: 1.55-6.32). This study revealed that 334 (66.4%) of the study participants (51.7% of cases and 70.8% of controls) had Comprehensive knowledge on HIV/AIDS. Lack of comprehensive knowledge was a significant predictor for refusal of provider initiated HIV testing and counseling. Clients who lack comprehensive knowledge on HIV/AIDS were 2.2 times more likely reject PITC than clients who have comprehensive knowledge, (AOR=2.2 (95%CI:1.16-4.50)). Similarly, about 19 (16.8%) of cases and 101 (27%) of controls perceived themselves at risk of HIV exposure. Lack of perceiving self as at risk of HIV exposure was found to be independently associated with refusal of PITC, (AOR=3.5 (95%CI: 1.46-8.26)) [Table 4]. The findings of this study also showed that those clients who have never heard about PITC information from health workers were 3.2 times more likely refuse PITC compared to those who reported health workers as their major sources, 3.2 (95%CI:1.59-6.58). However, awareness on benefit of provider initiated HIV testing and counseling, which has a correlation with source of PITC information from health workers with correlation coefficient of 0.41, was removed from final model as redundancy variable regardless of its association with outcome variable [Table 4].
| Variables | Refusals | Acceptors | COR (95%CI) | AOR (95%CI) | P-value |
| (Cases) | (Controls) | ||||
| Sex | |||||
| Male | 90 | 140 | 6.1(3.77-9.90) | 3.1(1.55-6.32) ** | 0.001 |
| Female | 26 | 247 | 1 | 1 | |
| Comprehensive knowledge | |||||
| No | 56 | 113 | 2.3 (1.48-3.46) | 2.2 (1.16-4.50)** | 0.017 |
| Yes | 60 | 274 | 1 | 1 | |
| Risk perception | |||||
| No | 94 | 273 | 1.8 (1.06-3.15) | 3.5 (1.46-8.26)** | 0.005 |
| Yes | 19 | 101 | 1 | 1 | |
| Source of PITC information from health workers | |||||
| No | 50 | 72 | 3.9 (2.40-6.21) | 3.2 (1.59-6.58)** | 0.001 |
| Yes | 47 | 261 | 1 | 1 | |
Note: ** represents statistically significant (p-value< 0.05); 1=used as a reference category
Table 4: Independent predictors for refusal of provider initiated HIV testing and counseling among OPD clients, in Kachabira District, April, 2015.
Discussion
This study examined the factors that determine refusal of provider initiated HIV testing and counseling among clients attending adult OPD services in Kachabira District Health centers. According to the findings, the majority of respondents had high awareness of existence of PITC services nearby health facilities, but considerably low proportion of clients (25.3%) were ever tested through provider initiation approach. On the other hand, being male, lack of comprehensive knowledge, reluctance to acknowledge self-risk perception and lack of exposure to information from health facilities were found to be statistically significant predictors for refusal of provider initiated HIV testing and counseling in multivariate analysis. Moreover, thinking self not at risk for HIV infection (77.6%), lack of interest and unpreparedness (67%), tested before (66.4%) and concerning about confidentiality (16.4%) were the main reasons for refusal of PITC.
Our findings showed that, only 16.3%) of cases and 25.8% of controls were ever tested by provider initiation method and there is no substantial difference between refusals and acceptors in utilizing PITC services. Which is significantly low compared to study conducted in Jimma town among OPD clients, 57% cases and 73% controls were ever tested by provider initiation approach [22]. Moreover, in Adama City among TB patients showed that 91% PITC acceptors and 81% PITC refusals were ever tested by provider initiation approach [40]. The possible explanations for this discrepancy may be related to health professionals’ low attention to initiate the clients at health facility, as the result significant number of clients were being missed and also it may be the study participants’ low health care seeking behavior or poor quality of health care facility as shown by health and health related indicators report of 2013 average number of OPD visits per person per year of SNNPR was only 0.29 which was significantly low when compared to the national target, 0.7 [19]. Clients who were never initiated by providers were 2 times more likely refuse the test than those of ever initiated by health providers, but failed to show significant association in multivariate analysis. This finding is in line with study conducted in Adama city among TB patients on assessment of acceptability of PIHCT [40].
Being male were significantly associated with the refusal of PITC. This finding is comparable with a study conducted in Nairobi urban informal settlements on determinants for HIV testing and counseling revealed that men were less likely to undergo HIV testing and counseling than women [41]. The possible reason for refusal of PITC by male participants may be males have less access to health facilities, but females have more access to health facilities due to the extensive opportunity of PITC at ANC clinics for PMTCT programs as indicated by the FMOH report of 2014, 100% of pregnant women in SNNPR were shown to have attended the antenatal clinic [20]. This promotes better opportunity for females to familiarize in PITC services than males, due to their frequent ANC visits, which in turn could influence their decision to take the test.
This study showed that lack of comprehensive knowledge was statistically significant difference between cases (51.7%) and controls (70.8%). Lack of comprehensive HIV/AIDS knowledge was significantly associated with the refusal of PITC which is in line with a cross sectional study among TB and non-TB patients on acceptability of PIHCT in Shashemane [31]. This may be due to Clients who lack comprehensive knowledge were less likely evaluate their risk status because of misunderstanding and lack of sufficient knowledge on HIV/AIDS transmission and prevention methods by study participants, which may leads to low risk perception on HIV infection, which subsequently enhance refusal of PITC services.
In this study, lack of risk perception to HIV infection was found to be independently associated with refusal of PITC. Studies concluded in different parts of Ethiopia showed that experience of risk perception for HIV by clients had been observed as the most influencing factor for refusal of HIV testing and counseling service [34-37]. The possible reason for this may be those patients who considered themselves as being not at risk of getting HIV in the past are less eager to know their sero-status in order to seek and utilize HIV prevention services as compared to self-perceived risk individuals. According to this study, 67% of study participants (74% cases and 64% controls) were married. Clients who were married were more likely to report a low-risk perception of acquiring HIV infection as a barrier to PITC assuming that both partners would be mutually faithful [33]. Once they tested negative they may consider themselves free from exposure to HIV virus and they hesitated subsequent exposures to the risk.
Another major determinant factor for refusal of provider initiated HIV testing and counseling is that lack of exposure to information about PITC from health workers and influenced significantly for refusal of PITC. This finding is comparable with study conducted in North Gondar on client initiated HIV counseling and testing service utilization revealed that majority of clients who got HIV/ AIDS information from health professionals were more likely utilize the available HIV counseling and testing service [37]. This finding is also consistent with a Study conducted in SNNPR on VCT utilization showed that health institutions were statistically significant source of information for utilization of HIV testing [39]. Health facilities would be expected to be the dominant source of information for PITC services. Those clients, who were not heard PITC information from health workers, could not access to PITC service nearby health facilities and also this may leads to low awareness on benefits of PITC, which in turn could finally influence clients’ decision for rejecting PITC.
The main obstacle for a successful HIV/AIDS prevention program is a low PITC acceptance rate among clients that increases the risk of acquiring or transmitting HIV virus to others, stigma and discrimination [7]. According to the findings of the present study, the main reasons for refusal of PITC by clients (refusals) were thinking self not at risk for HIV infection (77.6%), lack of interest and unpreparedness (67%), ever tested before (66.4%) and no sure of confidentiality (16.4%) which was in line with other studies findings done in Ethiopia and other African Courtiers. For example, in Adama city among TB clients [40], among TB patients in Arbaminch [38], qualitative study conducted in SSA countries [28], another study in Botswana [42],and in South Africa among TB patients [43,44], reported similar findings with the current study.
The strength of this study was all health centers were included to ensure representativeness. Both cases and controls should come from the same sources. Moreover, the selected controls had similar socio-cultural characteristics to the recruited cases. As the result cases and controls were more comparable. The common limitation of this study might be the fact that this study was institution-based; individuals who do not seek healthcare services would not be considered. Another limitation is that the information from clients about factors related to refusal of PITC was based on self-reported responses. This could be influenced by recall bias and social desirability bias. To minimize such biases, clarification of potential ambiguities and misunderstandings and probing for answers were carried out by interviewers. Even as individual related factors are primarily influential for refusal of PITC, other factors related to health care providers and institutional point of view was not considered in this study. Therefore, future studies that target study on the quality of provider initiated HIV testing and counseling service delivery in terms of health care providers and institutional perspectives could help for effective PITC service utilization by the clients. Despite these limitations, we believe that these findings might be a reasonable source of information for researchers and policymakers.
Conclusions and Recommendations
The current study conducted on determinants for refusal of PITC among adult OPD clients in Kachabira district Health centers shown that only one fourth of the participants were ever tested through PITC approach. Being male, lack of comprehensive knowledge and self-risk perception on HIV infection, poor exposure to information from health workers on PITC was found to be statistically significant predictors for refusal of PITC. Moreover, lack of thinking self as not at risk of HIV infection, fear and unpreparedness, ever tested before and no sure of confidentiality were found to be the main reasons for refusal of PITC among cases. IEC/BCC activities should be intensified to sensitize the clients and the community at large based on the findings of this study is of vital importance to improve PITC uptake.
Based on the findings of the study, the following recommendations are forwarded: Effective IEC/BCC interventions that promote HIV testing and tackling testing barriers must be incorporated in community conversation activities and ensuring regular monitoring of the activities at health facility level and at community level. Health care workers dedicate their time and efforts to encourage clients to utilize PITC service. Sustainable large-scale community conversation and social mobilization activities should be strengthened using existing structure will be an important intervention to tackle the barriers of PITC service.
Acknowledgment
We would like to thank Arba Minch University for giving an opportunity to undertake this study. We also extend appreciation to supervisor and data collectors for their active participation in collecting essential information during data collection period. Finally, our appreciation goes to the staffs of Kachabira district Health office and the health professionals of the health centers and study participants for their cooperation during the study period.
Competing Interest
None
Authors’ Contributions
TL conceived and designed the study, supervised data collection, analyzed the data and approved the final version. MT and WG contributed to the conception and design of the study, data analysis, and drafting and approval of the manuscript. In addition W.G. participated in interpretation of the findings, contributed to the drafting and writing of the manuscript, critical writing and revision of the manuscript and updated the manuscript to this version. All authors read and approved the manuscript.
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