Assessment of Home Based HIV Testing and Counseling services in enhancing access to treatment, care and HIV prevention in Kibera informal settlements, Nairobi, Kenya

Abstract

Home based testing and counseling is an innovative strategy geared to increase access and uptake of HIV testing services by the population by reaching those who for various reasons have not had a chance to test for HIV. Knowledge of one’s HIV status provides those who are negative with the opportunity to remain HIV-free through the HIV prevention messages delivered during testing and counselling. These prevention messages are given as a one time off session and it is expected that the individual fully utilizes the knowledge gained to prevent contracting HIV infection. Individuals diagnosed with HIV are reffered to access HIV treatment services, and are offered prevention messages to prevent re-infection and transmission of HIV to others as well. Home based testing and counseling (HBTC) services had been offered to the whole of Kibera slums community through their participation and by their involvement through the use of the Health belief model between 2009-2011 to increase uptake of services. The factors associataed with HBTC uptake, the effect of HBTC in enhancing; uptake and utilization of the prevention messages and access and retention on HIV treatment have not been investigated in Kibera informal settlement. The objective of this study was therefore to assess the role of home based testing and counseling in enhancing testing uptake; access and retention on ART and utilization of HIV prevention messages provided at HBTC in Kibera informal settlement in Nairobi city. This was a cross sectional mixed method study comprising of individual interviews using a structured quaestionnaire for individual interviews and focus group discussions using a focus group discussion guide. Data collected included; experiences with HIV testing and counseling, knowledge and utilization of HIV prevention messages including condom use; experiences with couple testing services and challenges associated with access to care and treatment for those who were diagnosed with HIV. Additionally HIV testing services were offered to those who reported HIV negative status. The quantitative data was analyzed for frequencies, cross tabulations and chi square test with significance set at 0.1%. Logistic regression was used to determine significant factors. Multiple correspondence analysis (MCA) was used to construct a composite prevention message index and calculate the weights using STATA 13 (Stata Corp, 2013) to determine the prevention messages received by the participants. Overall, 75% of the participants had tested in the previous HBTC with 97.7% being satisfied with services offered. Sex, age, education, marital status and previous experience with HBTC were all significantly associated with uptake of HBTC (p=0.001 for all these demographic characteristics respectively. Couple testing rates, dropped from 33.9% in 2009-2011 to 19.7% in 2012. Thematic content analysis was done for the qualitative data using Atlas ti 3.0. Negative consequences to the marriage stability as a result of HIV discordant results was the most commonly cited factor for fear of couple testing. Provision of prevention messages was significantly higher among HBTC clients compared to clients from other testing sites; partner reduction counselling (64% versus 52%) and faithfulness (78.3% versus 67%); P= 0.001 respectively. Participants reported no change from risky sexual behavior with condom use at 10.7%. Women had less odds (OR 0.46, 0.25-0.83 CI 95%) of practicing safer sex. Trust of the sexual partners and fear of suspicion of infidelity were the main reasons for not using condoms. The focus group discussions overwhelmingly reported multiple sexual partnerships among both HIV negative and positive participants. Prevalence of HIV among participants who believed they were free from HIV infection on account of negative HIV results at previous HBTC in the settlement was 2.4%. Enrolment to treatment services was 93% despite the delay associated with individuals seeking confirmation of positive results from other testing places and other individuals waiting until they became sick. HIV infected individuals experienced psychosocial barriers related to poor provider–client interpersonal relationships which influenced retention and adherence to care and treatment negatively. In conclusion, this study found that whereas HBTC promoted HIV testing uptake and although the prevention messages delivered during HBTC are accepted and appreciated in this community, their utilization to prevent HIV acquisition is low in both the HIV negative and positive individuals. Access to treatment is high but challenges exist that influence retention. Innovative strategies for change of normative beliefs about sexual behavior are urgently needed. Community wide education on HIV discordancy is required to mitigate the low couple testing found here associated with fear of consequences of HIV discordancy results in marriages. Continous provider capacity building is necessary to improve on client retention on treatment. Adherence counseling should be patient rather than hospital centered.