Cohen C, Montandon M, Carrico A, Shiboski S, et al. Association of attitudes and beliefs towards antiretroviral therapy with HIV-seroprevalence in the general population of Kisumu, Kenya. PLoS ONE 2009;4(3):e4573.
Provision of antiretroviral therapy (ART) to HIV-infected persons in sub-Saharan Africa is of high priority. In Kenya at the start of 2007, 44% of the estimated 250,000 persons in need of ART were receiving treatment, and 28% of ART-eligible persons in Kisumu were on treatment. The effect of ART on prevention of HIV transmission in the region has not been well established. Treatment may enhance prevention by reducing stigma, increasing testing rates and reducing risk behaviors among HIV-positive persons, and creating an infrastructure for prevention services.(1) In developing countries, however, treatment has been associated with decreased concern about contracting HIV and increased sexual risk behaviors.(2,3,4,5) To develop and prioritize appropriate prevention messages, especially about HIV treatment, more must be learned about attitudes and beliefs regarding ART and HIV/AIDS in sub-Saharan Africa.
To measure the association between ART-related attitudes and beliefs and prevalence of HIV, with a focus on attitudes of decreased concern regarding acquisition of HIV
Cross-sectional population-based survey
15- to 49-year-old residents of selected households
Attitudes and beliefs about HIV and severity of HIV in the ART era
Following formative research using rapid community assessment methods and focus groups, a two-stage sampling scheme was used. Within Kisumu, 23 sentinel clusters that were representative of the population were selected. An additional 17 systematically selected clusters were added, resulting in a total of 40 clusters (22 urban and 18 rural). All households in these clusters were enumerated, and the total number of households in our sampling frame was determined by the target sample size (2,000) adjusted for a 20% non-response rate and divided by the average number of eligible participants (2.15) per household. Households were selected by systematic random sampling.
A community mobilizer visited selected households a day or two before study staff visited the home to recruit participants. A total of three visits were made, and if none yielded eligible persons, the household was replaced with the next randomly selected household. Consenting participants completed a face-to-face interview in local languages and complied with a separate request to provide a blood sample.
Factor analysis was used to determine the structure of a 13-item assessment of ART-related attitudes and beliefs and the development of composite scores for these factors. Logistic regression was used to measure the association between the composite scores and HIV prevalence. Separate analyses with age as a covariate were conducted for men and women and restricted to the 71% of participants who indicated that they had heard of ART.
Of the 1,210 in the original sampling frame, 708 (59%) were contacted and 645 (53%) had at least one household member who participated. Of the 502 households that were replaced, 219 (43%) participated. There were a total of 864 participating households. Of the 3,376 eligible participants, 1,844 (55%) were contacted and 1,655 (91%) agreed. There were 1,508 participants who provided a blood sample for HIV testing.
Of those who underwent HIV serological testing, 25% of participants were between the ages of 15 and 19 years, 31% between 20 and 24 years, 17% between 25 and 29 years, 18% between 30 and 39 years and 9% between 40 and 49 years. Twenty-five percent of women and 16% of men who provided blood samples were HIV seropositive (odds ratio [OR] =1.7; 95% confidence interval [CI]: 1.3-2.8). HIV seroprevalence increased significantly with age. Eleven percent of the HIV-infected men and 14% of the infected women were previously aware of their infection.
Of the 71% of participants who had heard of ART, 87% thought treatment would be available for them if they were HIV-infected, 98% agreed that ART prolonged life, 23% believed that ART cured HIV, and 26% were not aware of ART-related side effects. Two factors - the belief that HIV is more controllable due to ART and ART-related risk compensation - adequately summarized the data on attitudes and beliefs. For the first factor, four items loaded strongly and for the second factor, seven items loaded strongly.
After controlling for age, ART-related risk compensation was associated with HIV prevalence among men but not among women (AOR=1.45; 95% CI: 1.16-1.81 and AOR=1.08; 95% CI: .89-1.31, respectively). The perception that HIV/AIDS is more controllable since the availability of ART was not statistically associated with HIV-seroprevalence for either men (AOR=1.28; 95% CI: .97-1.69) or women (AOR=.99; 95% CI: .82-1.20). A belief that ART cures HIV/AIDS was associated with increased HIV seroprevalence among men (AOR=2.14; 95% CI: 1.22-3.76) but not women (AOR=1.43; 95% CI: .93-2.21).
ART-related risk compensation and a belief that ART cures HIV were associated with increased HIV seroprevalence among men but not women.
This study was of high quality; sampling produced a representative sample, participation rate was high, HIV status was measured objectively, and the analysis was appropriate.
These results show that ART must be considered in terms of prevention programs for HIV-infected and -uninfected persons. Although the majority of participants had heard of ART, a quarter had not, suggesting that the general population must be better educated about HIV and ART. A greater emphasis on the realities of HIV infection in the presence of ART should be undertaken as part of the HIV prevention program in Kisumu and, given the complacency that accompanied ART availability in developed countries,(2,3,4,5) probably elsewhere in sub-Saharan Africa as well. In addition, the differences in the results between men and women merit further exploration.
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