Characteristics of the respondents
Between January and April 2005, a total of 780 men were enrolled into the study (Table ). The men were aged between 18 and 90 years with a median age of 32 years. Of the 780 men, 45.3% were Roman Catholic, 43.7% were Anglican while 6.7% were Muslim. Most of the men (71.3%) were married. Of these, 76.3% were in monogamous unions. The majority of the men were peasant farmers (58.1%), and 32% were earning less than one dollar a day (1US$ ≈ 1700 Uganda Shillings).
Frequency of voluntary counselling and testing among 780 men in Kasese district, Uganda, 2005
Prevalence of VCT use among men
Of the 780 men interviewed, 46 % (95% CI 40.8–51.2) had pre-test counselling while 25.9 % (95% CI 19.9–32) had tested for HIV. Thus the VCT drop out was 43.7 %. Of the 201 men who tested for HIV, 96% received their HIV test results. The prevalence of complete VCT use (pre-test counselling, HIV testing, post test counselling and receiving HIV test results) was 23.3% (95% CI 17.2–29.4) (Table ). The most common reason for taking an HIV test was to know the HIV sero-status (74.3%) followed by frequent illness (15.3%) and plans for marriage (15.3%). When asked if they were willing to seek VCT in the near future, the majority (79%) said they were willing to go for VCT. However, willingness to seek VCT in the future varied among the two groups being 74.9% among those who had never had VCT at all and 83.9% among those who had ever had VCT.
Knowledge and perceptions about VCT
The majority (80.1%) of the men said they were aware about the existence of the VCT program in their area. When asked what was involved in the VCT process, they mentioned pre-test counselling on HIV (78.6%), taking off blood for HIV testing (92.6%) and counselling on the prevention and control of HIV/AIDS (81.6%). Most men (98.7%) knew of a site offering VCT services in Bukonzo West. The majority of the men received information about VCT through the health workers (75.2%) but other sources of information included friends (12.8%), radio (13.9%), newspapers (6.9%), and community leaders (5.4%). Of the 780 participants interviewed, 94.9% said that VCT was important for the good of the individual and the family. However, most men were worried of taking an HIV test because to them having a positive result meant imminent death.
"You can die very soon if you tested positive because of worries" (Male, Nyakiyumbu FGD).
Only 9.1% of the men perceived themselves to be at a high risk of HIV and yet in the FGDs, the majority of the men, especially single men, considered themselves to be at high risk of HIV because of multiple sexual relationships.
"I have tested several times and been found negative. But this time am worried of my status because of the fourth wife whom I married recently" (Male 33 years, Karambi FGD).
Of the 780 respondents interviewed, 91.3% said that it was important to test together with their sexual partners. The findings from the FGDs showed that most men appreciated the importance of couple testing, with the majority saying that it would help them in family planning in the event of a positive HIV test result. On the contrary, men said that going to the health facility for HIV testing with a spouse was not common in their culture and would be considered as strange behaviour.
On the issue of discordance, over half of the men (61.8%) did not believe that discordant HIV results could exist. This view was supported by the FGDs where most men said it was not possible for one of the cohabiting partners to test HIV positive and the other HIV negative. They believed that if one of the partners was found HIV positive, then it was automatic that the other also had HIV infection.
"Some men have lost their wives due to HIV/AIDS but they lie to us that they were found HIV negative when they tested. This is not true" (Male, 35 years old, Nyakiyumbu FGD).
On disclosure of HIV test results, the majority of the men (81.8%) said they would disclose to their partners. There was, however, contradiction in the FGDs whereby the majority of the men felt that disclosure of HIV positive results would deny them their sexual rights and would imply that they brought the disease into the family.
"Some of our women are very emotional and if you disclosed to her, she might end up denying you your sexual rights" (Male, 34 years old, Key informant)
With regard to sexual partners, 35.1% of the men reported having two or more sexual partners. During the past one year, 24.9% of the men reported having had extramarital sex. Of those who had extra-marital sex, 76.8% used a condom on their last sexual encounter. Both men and women in the focus group discussions confirmed that multiple sexual relationships were common among the men and this could negatively affect VCT use. The participants felt that having VCT would not stop men from acquiring more sexual partners. Most participants said that the majority of the men live in doubt that they might be infected because of having multiple sexual partners.
"Men have many sexual partners and fear that they might be infected with HIV already" (Female, Kyasenda FGD).
Participants were asked if they had any fears about taking an HIV test and 41.3% said they had fear of taking the HIV test. When asked to mention the fears they had, they mentioned inaccuracy of the HIV testing (37.9%), stigma (57.1%), fear of divorce or separation from partner (38.8%) and lack of confidentiality (8.4%). The participants further mentioned that the majority of the men felt that if they tested positive, their families and the society would easily tell that they were infected. They expressed the feeling that the community might look at them differently and also deny them certain rights like holding political positions. Similar findings were obtained during the focus group discussions.
The participants were asked if they would feel comfortable if they were seen at the VCT site and the majority (83.1%) said they would feel comfortable. The commonest reasons given for feeling uncomfortable were fear of being labelled an HIV victim (67.4%), stigma (36.4%), and meeting a relative or familiar people (11.4%). These findings were also supported by the focus group discussions.
The participants were asked if they had any socio-cultural beliefs that might influence men to seek VCT services. Only 20% said that there were social beliefs that would influence men to seek VCT. Of those who said beliefs existed, the majority mentioned men's superiority over women (30.8%), if partner (wife) tested positive, then the man was also automatically positive (18.8%), widow inheritance/many sexual partners (17.3%) and witchcraft (14.7%). During the FGDs, the commonest belief mentioned was that of the superiority of men. Men superiority had a negative influence on the VCT seeking behaviour. Most decisions regarding health seeking behaviour among family members are dominated by the men and in most cases what the man decides is unchallenged by the entire family. Men also felt that once their sexual partners tested for HIV, they did not need to seek VCT because their results would be the same as those of their partners
Participants were asked whom they would consult before deciding to go for VCT. Of the 780 respondents, 40.9% said they would consult their partners/spouses, followed by friends (15.8%), health workers (15.0%) and 22.7% said they would not consult any body. The participants were asked what action they would take if they tested HIV positive. The majority said they would abstain from sex (33.8%), live positively (29%), seek treatment/join The AIDS Support Organisation (TASO) (24.5%), or simply keep quiet (5.9%).
Health service factors
Most men expressed the feeling that they would go somewhere else other than in the HSD, the majority preferring VCT sites outside Bukonzo West where the VCT counsellors do not know them. They feared that they would easily be identified and labelled as HIV victims. Some men also said that the VCT staff were being bribed and hence giving negative results to HIV positive clients.
"I don't trust those health workers because they might not keep people's secrets" (Male, Bwera FGD)
" I would prefer that the VCT Counsellors be people from other areas other than from Bukonzo" (Male & Single, FGD Karambi)
A sizeable proportion of the respondents (44.7%) said they would be unwilling to pay for the VCT services.
Of the 201 men who had ever undergone VCT, the main reasons given for choosing a particular VCT site were confidentiality (56.2%), proximity (37.8%), convenience (1.0%) and other (5.0%). The majority of the participants (91.6%) who had ever undergone VCT said they were satisfied with the VCT services. The majority of the participants (69%) lived within a radius of 5 kilometres from the nearest static VCT site. The commonest means of transport to the VCT sites was by walking (69.6%).
During the FGDs, the majority of the participants said that the VCT sites were few (only two) and were located very far from the people, hence making the VCT services inaccessible. Most of the men wanted VCT services to be extended to the villages or to their homes in order to save them the costs of time and transport.
Association between independent factors and VCT use among men
On unadjusted analysis, age 35 years or less (OR = 2.97, 95% CI 2.00–4.43); secondary or tertiary education (OR = 2.10, 95% CI 1.50–3.00); non-subsistence occupation (OR = 2.54, 95% CI 1.68–3.85); willingness to test for HIV with partner (OR = 5.33, 95% CI 1.92–14.85); willingness to disclose HIV results to partner (OR = 2.19, 95% CI 1.43–3.38); feeling comfortable with VCT site (OR = 2.71, 95% CI 1.54–4.77); wanting to know HIV status (OR = 0.19, 95% CI 0.13–0.27); and a monthly income of more than 50,000 Uganda Shillings (OR = 1.84, 95% CI 1.23–2.76) were associated with VCT use among men (Table ).
Unadjusted association between independent factors and voluntary counselling and testing among 780 men in Kasese district, Uganda, 2005
On logistic regression with complete VCT as the outcome, age (OR = 2.89, 95% CI 1.77–4.07), occupation (OR = 2.37, 95% CI 1.52–3.71), fear of taking an HIV test (OR = 0.54, 95% CI 0.37–0.79), testing together with a spouse/partner (OR = 3.01, 95% CI 1.02–8.83), and willingness to disclose HIV test results to their sexual partners (OR = 1.64, 95% CI 1.04–2.60) were independently associated with VCT use among men (Table ). Table shows results of logistic regression of factors associated with seeking pre-test counselling that included: to know the HIV sero-status (OR = 12.25, 95% CI 6.09–24.64); feeling comfortable with the VCT site (OR = 1.75, 95% CI 1.09–2.83); fear of being stigmatized (OR = 1.84, 95% CI 1.10–3.08); non-subsistence farmer (OR = 1.90, 95% CI 1.35–2.67); and confidentiality (OR = 15.91, 95% CI 5.54–45.74). Table shows results of logistic regression of factors associated with complete VCT among men who went for pre-test counselling that included: more than 7 years of education (OR = 2.9, 95% CI 1.1–7.8); to know the HIV sero-status (OR = 84.6, 95% CI 23.3 – 306.4); fear of inaccurate HIV test result (OR = 30.7, 95% CI 2.1 – 457.4); and confidentiality (OR = 53.1, 95% CI 10.8–261.8).
Logistic regression of independent factors associated with acceptance of VCT among 780 men in Kasese district, Uganda, 2005
Logistic regression of independent factors associated with pre-test counselling among 780 men in Kasese district, Uganda, 2005
Logistic regression of independent factors associated with complete VCT among 369 men seeking VCT in Kasese district, Uganda, 2005