Objective The aim of this study was to evaluate the effects of three strategies in increasing uptake of HIV counselling and testing (HCT) among male most-at-risk-population (M-MARPs) using programmatic data.
Design HIV prevention strategies were evaluated in a cross-sectional analysis.
Methods Three HCT strategies were implemented between July 2009 and July 2012 among men who have sex with men (MSM) and people who inject drugs (PWIDs) in four states in Nigeria. The first strategy (S1), involved key opinion leaders (KOLs) who referred M-MARPs to health facilities for HCT. The second strategy (S2) involved KOLs referring M-MARPs to nearby mobile HCT teams while the third (S3) involved mobile M-MARPs peers conducting the HCT. χ2 statistics were used to test for differences in the distribution of categorical variables across groups while logistic regression was used to measure the effect of the different strategies while controlling for confounding factors.
Results A total of 1988, 14 726 and 14 895 M-MARPs were offered HCT through S1, S2 and S3 strategies, respectively. Overall, S3 (13%) identified the highest proportion of HIV-positive M-MARPs compared with S1 (9%) and S2 (3%), p≤0.001. Also S3 (13%) identified the highest proportion of new HIV diagnosis compared with S1 (8%) and S2 (3%), respectively, p≤0.001. When controlled for age, marital status and occupation, MSM reached via S3 were 9 times (AOR: 9.21; 95% CI 5.57 to 15.23) more likely to uptake HCT when compared with S1 while PWIDs were 21 times (AOR: 20.90; 95% CI 17.33 to 25.21) more likely to uptake to HCT compared with those reached via S1.
Conclusions Peer-led HCT delivered by S3 had the highest impact on the total number of M-MARPs reached and in identifying HIV-positive M-MARPs and new testers. Training M-MARPs peers to provide HCT is a high impact approach in delivering HCT to M-MARPs.
- INJECTING DRUG USE
- OUTREACH SERVICES
- PROGRAM EVALUATION
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HIV counselling and testing (HCT) is a key intervention strategy for effective HIV control in most developing countries including Nigeria.1 It increases access and knowledge of HIV status, encourages safer sex and is an entry point for HIV care treatment and support services.1Several studies have highlighted the potential benefits of knowing one's HIV status through HCT including the adoption of risk reduction strategies (correct and consistent condom use, reduction of sexual partners), accessing palliative care, psychosocial support and antiretroviral treatment, all resulting in increased survival and labour productivity.2–6 Furthermore, HIV-positive individuals who undergo HCT are reported to practice safer sex more frequently and reduce their risky behaviours, thereby decreasing their likelihood of transmitting and acquiring sexually transmitted infections (STIs).7 However, poor access to health facilities, fatalism, HIV-related stigma, inadequate confidentiality, fear of receiving an HIV-positive test result, long distances to HCT sites and long delays in returning HIV test results have been reported to limit access to conventional HCT services.2 ,8 ,9 These constitute barriers to effective scale-up of HCT services in African countries.2 ,8 ,9
Strategies for implementing HCT can be influenced by varying factors such as donor targets, target population and access to the communities. Routine testing in hospitals and other healthcare facilities, for example, significantly increases uptake and case-finding among attendees of these facilities.1 ,10–12 Alternative HCT delivery models, such as mobile HCT, provider initiated HCT and home-based HCT have been shown to increase access to and uptake of HCT in the general population.9 ,13–17 However, there is limited information on the impact of these models on HCT uptake among male most-at-risk-populations (M-MARPs) such as men who have sex with men (MSM) and people who inject drugs (PWIDs). Despite the higher risk and burden of HIV among MSM and PWIDs,18–20 access and coverage of HCT services targeted at these subgroups are very limited in Nigeria. The 2007 Integrated Biological and Behavioural Surveillance Survey in Nigeria reported that less than 50% and 30% of MSM and PWIDs, respectively, had ever had an HIV test and received their results.21 A follow-up Integrated Biological and Behavioural Surveillance Survey in 2010 reported similar rates for ever tested and received HIV result among MSM, and less than 40% for PWIDs. Moreover, less than 40% of MSM and PWIDs had had an HIV test in the year preceding the survey.22 With data from programme implementation activities, we describe the characteristics of M-MARPs and evaluated the effects of three HCT strategies deployed in delivering mobile HCT to M-MARPs. Such information is vital and provides evidence to guide funding, programming and policy for HCT delivery services among M-MARPs in Nigeria.
Men's Health Network, Nigeria (MHNN) is an HIV prevention programme implemented by the Population Council with funding from the Centers for Disease Control and Prevention, Atlanta, USA. Prior to the initiation of the programme, HIV prevention services in Nigeria were all tailored towards heterosexual HIV prevention with no focus on higher sexual risks (such as unprotected same-gender and heterosexual anal intercourse) and injecting risk behaviour. Furthermore, no sexual diversity training had occurred among healthcare providers either in public or private institutions, which was thus a limitation in the provision of stigma-free and non-judgmental services for MSM. Recognising this gap, the MHNN was designed to provide and make accessible, quality HCT, STI syndromic management, condoms and lubricants for men with a focus on M-MARPs by harnessing private and public health sector service providers through a social franchise service delivery model.
HIV counselling and testing strategies
Three programmatic strategies were deployed in an integrated service delivery model in this study. A standard advocacy approach was employed in all three strategies to raise awareness among M-MARPs and solicit the support and cooperation of community leaders prior to entering any community.
The first programmatic strategy (S1), a standard mobile outreach service, was designed to provide HCT services through a network of mobile community-based key opinion leaders (KOLs). KOLs were M-MARPs community influencers and mobilisers who were trained as peer educators to deliver the minimum prevention package intervention (MPPI) to community members (clients). Clients reached with MPPI (including messages focused on abstinence, being faithful to a sexual partner, condom demonstration and distribution, as well as HCT promotion) in their communities were referred to MHNN designated M-MARP friendly health facilities for HCT. Each referred peer was issued a referral card with a unique identification number. The referral cards were in triplicates, two copies were issued to the peer with instructions to keep one and issue one to the HCT service provider while the KOL kept the third copy. The service provider was instructed to write the unique identification number on the card on the HCT client intake form to enable referral tracking. Each state had 10 KOLs trained to deliver the MPPI and HCT promotion through interpersonal communication and small group discussions to community members. The ratio of KOLs to clients per day in S1 was 1:25 per day. S1 ran from June 2009 to December 2010. Since S1 was the first intervention deployed within the M-MARP communities, it was assumed to be the baseline against which other strategies have been compared.
The second programmatic strategy (S2), an integrated mobile outreach service, brought together KOLs providing the same MPPI with dedicated HCT mobile teams (counsellors/testers). The combined team of KOLs and mobile counsellors and testers were deployed to deliver HCT services within MARP communities. While the KOL's role was to promote and create demand for HCT, the role of the teams of counsellors and testers was to deliver HCT to clients from site to site thus, eliminating the need for referral to facilities. The ratio of KOLs to clients in S2 was 1:20 per day and S2 ran from January to December 2011.
The third programmatic strategy (S3), a peer-based outreach service, engaged a network of mobile HCT teams which consisted of KOLs who were trained to become counsellors and testers and also trained to deliver the MPPI. Thus, MPPI and HCT services were delivered by KOLs within M-MARP communities. The ratio of counsellor and tester to clients in S3 was 1:20. S3 ran from January to July 2012.
In each programmatic strategy, the MPPI was designed to create demand for HCT services. The programme was implemented in Lagos and Oyo states in western Nigeria, Kaduna state in north-western Nigeria, and the Federal Capital Territory (FCT) in north-central Nigeria. These states were chosen based on high state-specific HIV prevalence21 among MSM in Lagos (25%), FCT (34%), Kaduna (16%) and Oyo (3%).
MSM were defined as men aged ≥15 years who had engaged in anal sex with another man in the past year prior to entering the MHNN programme. Male PWIDs were defined as men aged ≥15 years who had injected prescription and psychosocial drugs recreationally in the past year prior to entering the MHNN programme.
Data collection and management
Between July 2009 and July 2012, data were obtained using a structured precoded HIV counselling and testing client intake questionnaire. The questionnaire captured data on sociodemographic characteristics, sexual risk behaviours including type of sexual acts (vaginal and anal), unprotected sex with different types of sex partners, number of sex partners, engaging in transactional sex, history of STIs, as well as knowledge of HIV. All clients were offered HCT, thus uptake of HCT was measured as the proportion of all those offered HCT who were counselled, tested and received their results in keeping with the national indicator of complete HCT service provision.23 ,24
Informed consent was obtained and documented on the client intake forms from all clients who opted for HCT in keeping with the National HCT policy.23 Non-monetary incentives for using the service during each strategy were provided such as wrist bands and condoms valued at less than $1 and T-shirts valued at about $2. Data collected from clients were entered into Epi Data 3.1,25 coded and reviewed for completeness.
Rapid testing using blood samples obtained from a finger prick was used to conduct HIV test using the serial algorithm with Determine (Alere Medical, USA) and Unigold (Trinity Biotech, Bray, Ireland) simultaneously in accordance with Nigeria's national HIV testing protocol.23 Discordant results are subjected to another rapid test using Stat-Pak (Clearview, USA) as a tie-breaker. All participants received pretest and post-test counselling, and respondents who tested positive were referred to local M-MARP friendly persons in designated National comprehensive HIV care and treatment facilities for further management. Clients who declined testing were given a referral coupon to access free HIV testing and STI syndromic management in any of the health facilities partnering with MHNN at any time of their choice.
Data from Epi Data 3.1 were exported into Microsoft Excel and then into STATA V.12.1 software.26 We evaluated the Effects of the different strategies in a cross-sectional analysis. Analyses included descriptive statistics of demographic, behavioural and biological variables. χ2 statistics were used to test differences in the distribution of categorical variables across groups. Logistic regression analysis was used to assess associations between HCT strategies and HCT uptake. Crude associations were adjusted for sociodemographic variables (age, occupation, marital status) and key target population in multivariate analysis. Since MSM have different risk profiles from PWIDs, we conducted separate analysis for each key target group to assess the effect of the different HCT strategies on HCT uptake. Variables significant at p<0.2 were considered for inclusion in the multivariate analysis. Variables attaining significance at p value of ≤0.05 in the multivariate analysis were retained, based on the likelihood ratio test.
A total of 1988, 14 726 and 14 895 M-MARPs were offered HCT by S1, S2 and S3 strategies, respectively. Age distribution across all strategies was different (p<0.001). A higher proportion of clients were aged 19–25 years for S1 and S3 (table 1) while clients in their late 30s predominated in S2 (33%). The majority of the clients were single for S1 (72%) and S3 (59%) strategies, while the proportion of single and married clients were similar (50%) for S2. All three strategies attracted a substantial number of first-time testers, with S3 attracting the most (90%) and S1 and S2 at 89% and 85%, respectively.
Uptake of HCT and HIV prevalence
Overall, HCT uptake was 87% with S3 yielding the highest uptake at 94%. HCT uptake was 78% and 84% for S1 and S2, respectively. All three strategies attracted a substantial number of first-time testers, with S3 attracting the most (90%). Table 2 shows HIV prevalence by subgroups. Overall, HIV prevalence was highest in S3 (13%) and lowest in S2 (3%; p<0.001). Among those who tested HIV-positive, 84%, 83% and 98% (p<0.001) of those reached via S1, S2 and S3, respectively, received their results (see online supplementary figure). Clients aged 19–25 years had the highest HIV prevalence in S1 and those 35 years and above had the highest prevalence in S3. Among the first-time testers, S3 accounted for the highest proportion of HIV-positive clients (13%) while S2 reported the lowest proportion (3%).
Effect of HCT strategies on HCT uptake
Table 3 outlines results from multivariate logistic regression used to evaluate the association of HCT strategies on HCT uptake by target group. For MSM, controlling for age (<25 years vs. ≥25 years), marital status (single vs. married) MSM reached with HIV prevention interventions via S2 were less likely to uptake HCT (AOR: 0.29; 95% CI 0.22 to 0.40) while those reached via S3 were more likely to uptake HCT (AOR: 9.21; 95% CI 5.57 to 15.23). Among PWIDs those reached via S2 (AOR: 3.12; 95% CI 2.65 to 3.66) and S3 (AOR: 20.90; 95% CI 17.33 to 25.21) were more likely to accept HCT when compared with those reached via S1.
The role of HCT in reducing the burden of HIV cannot be overemphasised. Given that men have been shown to have poor health-seeking behaviours,27–29 effective evidence-based strategies are urgently needed to increase uptake of HCT in line with the call for universal access.
This is the first study to evaluate the effects of different programmatic strategies on HCT uptake among M-MARPs in Nigeria. Between 2007 and 2010, less than 50% of MSM and PWIDs had ever had an HIV test and received their result21 ,22 while less than 20% of the general population had ever been tested for HIV.30
The National Institute for Health and Clinical Excellence, UK, recommends that MSM have an HCT test at least once a year and additional tests if the client has a new sex partner; engages in high-risk sexual intercourse; is diagnosed with another STI; requests a sexual health screen; or presents with an HIV indicator disease.w1 w2 Similarly, US guidelines recommend annual screening for MSM who have had or whose sex partners have had more than one sex partner since their most recent HIV test.w1 The Nigerian National Prevention plan on HIV has set a target of 50% of MARPs to be tested by 2015 with no indication of the frequency of testing.w3 While there are no state-level or national estimates of the absolute number of MARPs in Nigeria to provide accurate benchmarks for the achievement of this target, it is safe to speculate that this target is unlikely to be met for M-MARPs and much less, the goal of universal access proposed by WHO given the limited funding and availability of interventions for M-MARPs in Nigeria.
All three strategies reached a large proportion of first-time testers, thereby adequately addressing one of three HIV prevention control priorities—expanding knowledge of HIV status in previously untested clients. The progressive increase in the total number of M-MARPs reached by S2 and S3 compared with S1 may be attributable to the reduction in the referral processes including cost of transportation to the referral clinic. S3 yielded the highest proportion of first-time testers as well as the highest HIV prevalence among first-time testers, suggesting this strategy as the most effective for M-MARPs. While S2 was able to reach a large number of M-MARPs, it identified the least proportion of HIV-positive M-MARPs. However when analysed by key target populations, MSM reached via S2 were less likely to uptake HCT compared with PWIDs where S2 showed a significant increase in HCT uptake. The marked significant effect of S3 compared with S1 can be attributed to the social characteristics of this group, which relate through peer networks based on their stigmatisation and criminalisation in Nigeria. In addition the training of peers to provide behaviour change communications and HCT improves the overall quality of service provided by a KOL and is fundamental in maximising efficiency in HIV prevention interventions for MSM.
There is limited evidence of the effectiveness of community-based and peer-led strategies on HCT uptake.w4 A study from the USA showed no significant difference between the uptake of HIV tests included with a package of other tests (STI, alcohol and drug dependence and depression) offered in outreach settings (bars) and HIV tests provided alone.w5 Two non-randomised studies from the UK evaluated the effectiveness of peer-led community-based risk-reduction campaigns and found that both of these campaigns were ineffective in increasing HIV testing among a group of MSM.w6 w7 Also in the USA, a randomised controlled evaluation study of an intensive weekend residential programme for black MSM led by trained MSM peers reported a small but significant improvement in HIV testing rates among participants at the 6th month follow-up.w8 A study in Uganda showed that, although door-to-door HCT reached a large number of the population, it did not have a high yield of HIV-positive clients and was the second least cost-effective method when compared with hospital-based, stand-alone and household-member HCT models. As donor funding on HIV dwindles, it is imperative that evidence-based methods must be deployed in the design and implementation of HCT models to appropriately impact the target population.
This study has some limitations. The period and duration of implementation of each strategy differed and may have affected total number of M-MARPs reached, however the different effect of S2 and S3 compared with S1 despite the large number of M-MARPs reached via these strategies suggests that strategy matters in providing HIV prevention intervention for marginalised groups. In addition temporal trends such as improved efficiency of the KOLs, increased awareness of MSM to HIV and HCT and willingness to test which may not be attributable to the MHNN project could not be accounted for and thus could not be controlled for in the analysis. Second, data was available for only M-MARPs and thus the effect of these strategies on female MARPs such as female PWIDs and women who sell sex remains unknown. Another limitation was that strategies were deployed sequentially and thus there may have been a washover effect/period from one strategy to another. However, strategies were implemented in different locations across the states to increase coverage of interventions and thus limit potential washover effects. In addition, because only S3 was implemented in Kaduna state, the potential confounding effect of states could not be assessed in our model.
In conclusion, to our knowledge, this is the first study that has evaluated the effect of different community peer-based strategies on the uptake of HCT among M-MARPs in Africa. Training peers to serve as counsellors as well as provide HCT is a viable strategy in increasing uptake of HCT among M-MARPs. This strategy yielded a high number of first-time testers among M-MARPs and a high proportion of undiagnosed HIV-positive clients who would otherwise miss opportunities for linkages to antiretroviral care, treatment and support services. The National HIV prevention plan needs to align its goals to WHO's goal of universal access and promote annual testing for all MARPs in the country.
Training male MARPs peers to provide HIV counselling and testing (HCT) is a high impact approach in delivering HCT to male MARPs.
Training male MARPs peers to provide HCT is effective in reaching first-time testers among members of this community.
HCT uptake among male most-at-risk populations can be increased if access to HCT is provided.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online references
- Data supplement 2 - Online figure
Handling editor Jackie A Cassell
Acknowledgements The authors thank their community-based partners, field staff and clients who have availed themselves of their HIV prevention services. The authors especially thank Lolade Abiodun, Femi Adeyemo, Otibho Obianwu, Segun Sangowawa, Akin Toyose and the entire MHNN project team.
Contributors SA and GE conceived the study. SA, JN and GE designed the study. AO and GE conducted statistical analysis. JN, GE and AO drafted the manuscript. SA, BA and TL provided critical review of the manuscript. All authors read and approved the final manuscript.
Funding This research was supported via the MHNN project with funds by the Centers for Disease Control and Prevention (CDC), Atlanta, with grant number-1U2GPS001066-01.
Competing interests None declared.
Ethics approval National Center for HIV/AIDS, Viral Hepatitis, STDs and TB Prevention; CDC, Atlanta; The Population Council, New York; and the Nigerian Institute of Medical Research (NIMR), Lagos, Nigeria.
Provenance and peer review Not commissioned; externally peer reviewed.