Date Published: December , 2017
Publisher: Makerere Medical School
Author(s): Elizabeth Broel, Larissa Brunner Huber, Jan Warren-Findlow, Elizabeth Racine.
Approximately 70% of global HIV infections are located in sub-Saharan Africa, and the prevalence of HIV infection in Kenya remains high.
This study examined the association between client type (general population, commercial sex worker [CSW], or truck driver) and consistent condom use with steady and unsteady partners.
Self-reported data included in the Kenyan Ministry of Health 2010–2011 National HIV Testing and Counseling Registry were used (n=11,567). Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained using logistic regression.
After adjustment, CSWs and truck drivers had decreased odds of consistent condom use with steady partners compared to the general population (OR=0.52; 95% CI: 0.41–0.67 and OR=0.29; 95% CI: 0.13–0.63; respectively). CSWs had 1.95 times the odds of consistent condom use (95% CI: 1.58–2.42) and truck drivers had 0.64 times the odds of consistent condom use with unsteady partners (95% CI: 0.45–0.91) compared to the general population.
Although CSWs consistently use condoms with their unsteady partners, truck drivers do not consistently use condoms with any partners. Future HIV prevention efforts should target CSWs and truck drivers to increase consistent condom use with all partners. Such efforts may decrease the prevalence of HIV in Kenya.
The prevalence of Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) is disproportionately high in sub-Saharan Africa, with nearly 70% of the new global HIV infections located in this region1. While the overall estimated incidence rates of HIV/AIDS declined over 25% in 22 sub-Saharan African countries between 2001 and 2009, the estimated HIV/AIDS rates in Kenya remained stable2. In 2014, there were an estimated 1.4 million people living with HIV/AIDS in Kenya3.
This cross-sectional study used data from the Kenyan Ministry of Health 2010–2011 National HTC Registry. The Kenyan Ministry of Health developed a national strategic plan (1999–2004) in response to the HIV epidemic in Kenya, and introduced comprehensive and standardized National HTC operations into the public healthcare system28. National HTC centers were developed to target those not yet infected with HIV, and to identify those infected with HIV and provide proper care28. Both static and mobile HTC models are available. Static sites include: integrated HTC centers located in the same structure as other physical health services; stand-alone HTC centers not associated with healthcare facilities; HTC centers connected to ongoing community or church programs; and HTC centers targeting special needs groups such as youth, MARPs, rape victims, and disabled persons. Mobile or outreach sites include workplace or home based counselling; vehicles with private counselling rooms; temporary tents; utilization of pre-existing facilities; and other mechanisms such as bicycles or camels4. Client HTC registration collects information about demographics, risky sexual behavior, HIV and other test results, distribution of condoms, and referral recommendations. Utilization of HTC services is strictly voluntary and informed consent is obtained prior to delivery of any HTC services28.
Type of HTC client was the main exposure in this study. MARPs assessed in this study included CSWs and truck drivers. MARPs can be identified several ways: through self-report while completing the HTC registration form; by counselors while discussing occupation or risky behavior; or by trained peer educators. Regardless of how the MARP is identified, they are issued a Unique Identifying Number and their data are entered into a separate database dedicated to MARPs. HTC clients were classified into three categories for the purposes of this study: general population (non-MARP; referent), CSWs (MARP), and truck drivers (MARP).
The main outcome of interest was risky sexual behaviors; specifically, condom use with steady and unsteady partners. Information regarding condom use was collected on the National HTC registration forms, and assessed during the consultation with a trained counselor, by querying about condom use in the last 12 months with steady and unsteady partners. Participants who answered that they did not have a steady/unsteady partner, had not had sex in the last 12 months, or had never had sex were excluded from the analysis as appropriate. Participants who indicated they always used condoms were considered to consistently use condoms while individuals who never or sometimes used condoms were considered to not use condoms consistently.
Information on demographic and lifestyle characteristics collected on the National HTC registration forms were considered as potential confounding factors. Specifically, the following potential confounders were included: age, sex, education, marital status, knowing HIV status (i.e. in response to the question “Has client had an HIV test before?” the options were “No”; “Yes, Negative”; “Yes, Positive”; and “Yes, Do Not Know Result”), and whether the client came alone or as a couple29–32.
Frequencies and percentages for all demographic and lifestyle characteristics were summarized for all participants according to exposure status. Logistic regression was used to calculate unadjusted odds ratios (ORs) and 95% confidence intervals (CIs) to assess the crude association between each type of HTC client and condom use with steady and unsteady partners. Additionally, other factors associated with condom use with steady and unsteady partners were identified. Multivariate logistic regression was used to calculate adjusted ORs and 95% CIs. Covariates were included in the model one at a time to determine if confounding was present. A covariate was considered a confounder if the magnitude of the OR changed by >10%34. All analyses were performed using SAS (version 9.2; SAS Institute Inc., Cary, North Carolina).
This study of consistent condom use among HTC clients in Kenya found that truck drivers were less likely to consistently use condoms with both steady and unsteady partners as compared to the general population. In comparison, CSWs were less likely to use condoms consistently with steady partners and more likely to use condoms consistently with unsteady partners as compared to the general population.
While additional research is needed to understand consistent condom use among MARPs, the information from this study can be useful for public health practitioners and HTC administrators in Kenya. By knowing which sub-populations of MARPs are consistently using condoms, practitioners will know which populations need to be targeted for continuing HIV prevention efforts. While the majority of CSWs are using condoms consistently with unsteady partners, intervention efforts need to focus on also promoting consistent condom use with steady partners. Additionally, public health practitioners should target interventions to truck drivers to promote consistent condom use with both steady and unsteady partners. Because knowing one’s HIV status is a cornerstone of HIV prevention, the association between knowing HIV status and consistent condom use also has important public health implications for continuing HIV prevention efforts39. Intervention efforts combining promotion of consistent condom use and knowing one’s HIV status may be a more effective method of HIV prevention.