A total of 1221 adults ages 15 to 49 who presented to our mobile clinic with medical complaints or requesting screening services received an HIV test. We selected 317 (26%) to complete study questionnaires based on interviewer and patient availability.
The PITC group consisted of 681 (56%) patients. Of these, only one-third (n=222; 33%) would have been referred for testing in the absence of a PITC approach, including 142 (64%) only via client request, 63 (28%) only via the provider’s clinical suspicion of HIV infection, and 17 (8%) via both. The standard non-PITC group consisted of 540 (44%) patients, including 454 (84%) referred for testing strictly by client request, 59 (11%) referred strictly by provider clinical suspicion of HIV infection, and 27 (5%) referred for both (). Altogether, PITC tested 114 adults per practitioner, while standard non-PITC tested 34 adults per practitioner. PITC and standard non-PITC groups were similar in all baseline characteristics except for sex (proportionately more women in PITC vs. standard non-PITC groups, p < 0.01) and clinic location (p < 0.01) ().
Population characteristics in the Provider-Initiated Testing and Counseling (PITC) and standard non-PITC groups in rural southern Zambia, 2008
Most participants were female (72%) and married (66%). The mean age of the study population was 30 years [interquartile range (IQR) 22-38]. Among married males, 28% reported two or more wives. Among married females, 30% reported that their husbands had multiple wives. Only 59% of patients had a full primary education, and 76% reported at least one health clinic visit in the last 12 months.
Overall, 53% of patients reported a prior HIV test. Among those previously tested, 37% had been tested in the last 12 months, primarily through regional sites providing standard non-PITC services. When adjusted for other variables, being female (OR 2.4; 95% CI 1.1 to 4.0; p<0.001) and possessing fewer stigmatizing attitudes towards PLWHA (OR: 1.4; 95% CI 1.1 to 1.9; p=0.02) were predictive of prior HIV testing (Data not shown). Older age was associated with prior HIV testing, but when adjusted for sex, knowledge, stigma, and education, its effect may have been due to chance (p=0.07). Prior HIV testing was not significantly associated with clinic location (p=0.65) or additional health clinic visits in the last 12 months (p=0.10) (data not shown). Because marital status had a significant association with HIV testing, we ran a second multivariable model of HIV testing history adjusting for marital status that revealed no effect modification.
Of the 1221 adults who underwent HIV testing, 130 were found to be seropositive, resulting in an overall prevalence of 10.6% (95% CI: 2.9% to 12.4%). HIV positive individuals tended to be older than uninfected individuals (p < 0.01), and had a greater number of sexual partners in the last 12 months (p = 0.05) (). HIV status was not significantly associated with either patient sex (p = 0.34) or prior HIV testing (p = 0.86), though adults previously tested for HIV had a lower HIV prevalence (10.1%) than those never tested (11.3%). HIV prevalence in Kanchindu (6.4%) was significantly lower than in the other three sites (p < 0.01).
Population Characteristics by HIV Status in rural southern Zambia, 2008
HIV prevalence did not differ by testing referral type (). HIV prevalence in the PITC group was 11.2% (95% CI 8.8% to 13.5%), whereas prevalence in the standard non-PITC group was 10.0% (95% CI 7.5% to 12.5%). Among all patients who requested HIV testing, prevalence was 10.4%. In all patients whose clinical presentation prompted referral for HIV testing, prevalence was 16.3%. In the subgroup of PITC patients without additional indication for testing (i.e., no client request or clinical presentation implicating HIV), prevalence was 9.6%. There was no significant difference in HIV prevalence rates according to testing strategy (p = 0.08). Using 6 providers PITC detected 76 cases of HIV, while standard non-PITC detected 54 cases with 16 providers. Thus, PITC detected more than three times more HIV infections per practitioner than standard non-PITC (12.7 vs. 3.4).
Multivariable analysis of HIV status adjusting for selected patient characteristics did not alter our results (). The PITC group was not associated with a lower prevalence of HIV than the standard non-PITC group (OR: 1.01; 95% CI 0.67 to 1.52; p = 0.95). Moreover, when compared to all study patients who either requested testing and/or had a clinical presentation suggesting HIV, the subgroup of PITC patients without additional indications for HIV testing did not have a statistically different HIV prevalence (OR: 0.83; 95% CI 0.55 to 1.24; p = 0.36).
Predictors of HIV Infection in rural southern Zambia, 2008
Of the patients who completed questionnaires, most (73%) reported prior knowledge of the concept of routine opt-out HIV testing, and 96% reported being “in favor” of PITC. Previous HIV testing was associated with knowledge of PITC (p=0.02) (data not shown).
Patients Declining HIV Testing
Due to clinic limitations in monitoring patient flow, it was logistically not possible to track adults who either did not consent for HIV testing or defaulted prior to receiving HIV testing. However, among those not receiving HIV testing, 89 completed questionnaires. This sample was compared to the 317 adults with questionnaires who were tested. They were found to be similar in all baseline demographic characteristics and attitudes toward PITC. Information regarding reasons for declining an HIV test was not formally assessed. Anecdotally, the most common reasons cited for declining an HIV test were known HIV positivity, recent prior HIV testing, and religious/cultural conflicts.