DECLARATION
I hereby declare that this dissertation titled “EFFECT OF HEALTH EDUCATION ON
HIV/AIDS RISK BEHAVIOURS AND STIGMATIZATION ATTITUDES
AMONG ADOLESCENTS IN OGUN STATE, NIGERIA” is my original and individual work.
It was written under the supervision of Dr O.E. Amoran.
I also declare that this dissertation has not been submitted anywhere else in part or in full for any other examination.
………………………………………………..
Dr Oke, Olalekan Adeniyi
Department of Community Medicine and Primary Care
Olabisi Onabanjo University Teaching Hospital, Sagamu,
Ogun State.
DEDICATION
1
This work is dedicated to Almighty God from whom all blessings and wisdom flow for making it a reality.
Also in loving memory of my Late father Mr Joseph Kehinde OKE for leaving me with an enduring legacy – Education!
CERTIFICATION
I hereby certify that this dissertation was written by Dr Oke Olalekan A. under my supervision.
Supervisor:
2
………………………………………
Dr O.E. Amoran
Department of Community Medicine and Primary Care,
Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State
………………………………………………
Dr O. J. Daniel
Head of Department of Community Medicine and Primary Care,
Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State
ACKNOWLEDGMENTS
I appreciate the enormous efforts of my supervisor, Dr. O.E. Amoran whose guidance and painstaking efforts were instrumental to the actualisation of this research work. I am deeply grateful to Dr O.J. Daniel, the Head of Department of Community Medicine and
Primary Care, Olabisi Onabanjo University Teaching Hospital, Sagamu and the entire team of consultants and residents for their useful critique, advice and contributions.
The entire managements of Ado-Odo/Ota and Ifo Local Governments for kindly granting the approval for the conduct of the research in their communities. Mr Kolawole Ogun and his team of Town Planning officials of Ado-Odo/Ota Local Government as well as Mrs
3
F. Atobasere and her team of Town Planning officials of Ifo Local Government are recognised for their assistance in the course of this work.
The painstaking efforts of Ms Temitope Ibrahim, a Family Life Health Education (FLHE) trained teacher is appreciated especially during the training sessions for the intervention group as well as the wonderful contributions and assistance of Mr Damilola Shodiya and his team at Positive Outreach Foundation (a local community based organisation) were invaluable throughout the course of the study. I also wish to mention the assistance of the two HIV positive individuals (who have granted me permission to mention their names) that assisted me in the training sessions for the intervention group – Mr Kolawole P.
Ekanoye and Ms F.A. Komolafe.
I acknowledge the innumerable contributions of Dr Daniel A. Adesanya – the Medical
Officer of Health, Ado-odo/Ota Local Government who spared no resource at his disposal in facilitating this research in his LGA. I must not fail to specially acknowledge and appreciate Prof. A. A. Onayade for the inspiration, words of advice and encouragement that propelled me. I am immensely thankful to Bishop Taiwo Akinola of
Rhema Christian Church and Towers for his support and prayers. Special mention also of
Drs Oyesola of the Department Community Medicine, Federal Medical Centre, Abeokuta and Dr Clifford Okike of FMC, Asaba, Delta State for their kind inputs. I remain in the debt of my brothers and senior colleagues in the specialty of Public Health – Drs Kehinde
Fatungase and Babatunde Ipaye who never relented in pushing me all the way towards attaining the goal of bringing this work into reality.
My heartfelt gratitude goes to my friend and colleague, Dr Tunde Adedokun of the
Department of Epidemiology and Medical Statistics, University of Ibadan for his
4 wonderful contributions. To my bosses in the Local Government Service, in Ogun State –
Engrs A.O. Egunjobi and B.A.T. Odunlami FNSE, I deeply appreciate you for your huge support. I also appreciate the entire management of the library of Bells University of
Technology, Ota, Ogun State for granting permission for use of their facility.
Finally, I acknowledge and remain deeply gratified by the encouragement and support of my entire family especially, from my dear wife Adepeju and our two lovely children –
Oluwaseyi and Aanuoluwapo Oke.
5
TABLE OF CONTENTS
1. Declaration ……………………………………………………….i
2. Dedication……………………………………………………..ii
3. Certification ……………………………………………………iii
4. Acknowledgements……………………………………………..iv – v
5. Abstract…………………………………………………………vi - vii
6. Table of contents ………………………………………………viii
7. List of Abbreviations …………………………………………ix
8. Chapter One: Introduction
i. 1.1 Background to the study………………………….1-4
ii. 1.2 Problem Statement………………………………...5-6
iii. 1.3 Justification………………………………………...7-9
iv. 1.4 Objectives of the study…………………………….10
v. 1.5 Scope and Focus of the Study……………………..11-12
9. Chapter Two: Literature Review
i. 2.1 Epidemiology of HIV/AIDS………..……………….13-16
ii. 2.2 Virology and Transmission of HIV….…………….16-20
iii. 2.3 HIV/AIDS Knowledge and Attitude………….…….21-23
iv. 2.4 Sexual Behaviour……………………………………23-27
v. 2.5 HIV/AIDS and Drug Abuse and Addiction…………27-28
vi. 2.6 Stigma & Discrimination Associated with HIV/AIDS…28-30
vii. 2.7 Stigma and Discrimination Reduction……….…….30-35
viii. 2.8 Signs and Symptoms of HIV/AIDS………………..36-38
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ix. 2.9 Diagnosis of HIV…………………………………….38-40
x. 2.10 Classification of HIV Infection……………………40-41
xi. 2.11 Prevention of HIV/AIDS……...…………………..41-46
xii. 2.12 Management of HIV/AIDS………………………..46-52
xiii. 2.13 Impact of HIV/AIDS………………………………..52-55
xiv. 2.14 Religion and HIV/AIDS….……………………….55-58
xv. 2.15 Role of Government and Non-Governmental Organisations in
Addressing HIV/AIDS Stigma…………………………….58-59
10. Chapter Three: Materials and Methods
i. 3.1 Study Area……………………………………….60-63
ii. 3.2 Study Population…………………………………63
iii. 3.3 Study design……………………………………..63
a) 3.3.1 Pre-Intervention Phase………………...64-66
b) 3.3.2 Intervention Activities…………………66-67
c) 3.3.3 Post-Intervention Phase………………67-68
iv. 3.4 Sample size determination……………………....68-69
v. 3.5 Subject Selection and Sampling Methods….……70-73
a) 3.5.1 Inclusion Criteria……………………….73
vi. 3.6 Research Instrument and Data collection…….....73-75
vii. 3.7 Data management and analysis……………...... 75-78
viii. 3.8 Ethical Considerations…………………………..78-79
ix. 3.9 Limitations……………………………………….79
11. Chapter Four: Results
7
i. Results of Quantitative Study……………………….80 – 118
ii. Results of Qualitative Study (FGDs)……………….119 - 128
12. Chapter Five: Discussion……………………………………..129 - 147
13. References ……………………………..…………………….148 - 170
14. Appendix 1 (Study Questionnaire)……..…………………..171 - 180
15. Appendix 2 (Informed Consent Form).…………………….181 – 186
16. Appendix 3 (Focus Group Discussion Guide)………………187 - 191
17. Appendix 4: Ogun State Senatorial Zones and LGAs………….192
18. Appendix 5: List of Wards in Selected LGAs…………………..193-194
19. Appendix 6: Workplan of Activities…………………………….195-198
20. Appendix 7: NPMCN Approval for the study…………………199
21. Appendix 8: Health Research Ethics Committee Approval……200
22. Appendix 9: Official Permission by Ado-Odo/Ota LGA………..201
23. Appendix 10: Official Permission by Ifo LGA…………………….202
8
ABSTRACT
Background: Adolescents in Nigeria constitute an important group in HIV control due to their vulnerability and sexual inexperience. Even though there is a high level of awareness about HIV among young people in Nigeria, there are still relatively high levels of misconceptions and stigma. Improvement of knowledge about HIV transmission and prevention and correction of stigma and discriminatory attitudes will help in the fight against HIV among young persons in Nigeria. The objective of this study is to determine the effect of health education on HIV/AIDS risk behaviours and stigmatization attitudes among adolescents in Ogun State, Nigeria.
Methodology: A quasi-experimental study with a pre and post test design was used to determine the effect of a structured health education programme on HIV/AIDS risk behaviours and stigmatization attitudes in two Local Government Areas in Ogun State. A multistage sampling technique was used to select 215 study participants each in the intervention and control groups. Semi-structured interviewer-administered questionnaires were used to collect data on HIV/AIDS knowledge and misconceptions, personal risk perception, stigmatizing attitudes towards PLWHA, HIV testing, and sexual behaviour.
Stigma, HIV Knowledge and sexual behaviour were compared over the follow up times and between the intervention and control groups using Paired t test, McNemar’s Chi square test, Independent samples t test and the z test. Multiple linear regression was also applied. Level of significance of all tests was at 5%.
Results: At baseline, participants in the intervention and control groups were not significantly different concerning age (X2 = 2.69, p = 0.101), gender (X2 = 2.31, p =
9
0.128), parents’ marital status (X2 = 0.12, p = 0.729), father’s education (X2 = 2.88, P
=0.237), mother’s education (X2 = 4.75, p = 0.093) and family type (X2 = 5.57, p =
0.062). There was a 42.5% reduction in risky sexual behaviour in the intervention group compared to 27.4% of controls at 4 months compared to baseline (Z = 1.34, p = 0.163).
The change in proportion that had sex 12 months before the study was significantly higher among controls (19.2%) compared to the intervention group (8.8%) (Z = 2.94, p =
0.002). Also, condom use last sex was much improved in the intervention (72.2%) compared to control group (32.5%) (Z = 3.04, p = 0.003). There was no significant difference in the reduction in stigma scores between the intervention (mean 2.2, SD =
4.8) and control groups (1.8 (SD = 5.4) (U = 11586, p = 0.952).
However, there was a significantly higher improvement in knowledge scores among adolescents in the intervention (mean = 1.3) compared to control groups (mean = 0.6) (p
= 0.043). There was an increase in the proportion that ever tested for HIV of 3.2% in the intervention group compared to a reduction of 4.2% for the control group (Z = 3.82, p <
0.001). Multiple linear regression of stigma scores showed that respondents from polygamous homes or widowed parents had significantly higher mean scores (95% CI =
0.01 – 1.67, p = 0.049) compared to those from monogamous homes. Multivariate analysis also revealed that risky behaviours were also significantly higher among adolescents whose fathers had lower education (X2 = 9.63, p = 0.008).
Conclusion: This interventional study has found a significant decrease in the proportion initiating sex, and an increase in condom use last sex act. There was no difference in accepting attitudes towards people living with HIV/AIDS (PLWHAs) at 4 months post intervention between the intervention and control groups. Community based interventions
10 could be effective in reducing some aspects of sexual behaviour but not stigma towards
PLWHAs among adolescents. It is thus recommended that stigma reduction interventions should focus more on adolescents from polygamous homes and those with poor HIV knowledge as this study has shown higher stigmatizing attitudes among them.
LIST OF ABBREVIATIONS
. HCT – HIV Counselling and Testing . HIV – Human Immuno-deficiency Virus . AIDS – Acquired Immune Deficiency Syndrome . STI – Sexually Transmitted Infections . FP – Family Planning . WHO – World Health Organisation . MSM – Men having sexual intercourse with men . IPPF – International Planned Parenthood Federation . LGA – Local Government Area . OGSACA – Ogun State Agency for the Control of HIV/AIDS . AFHS – Adolescent Friendly Health Services . BCC – Behaviour Change Communication . SPARCS – Specific AIDS Reproductive and Child Health Survey . PLWHA – People Living With HIV/AIDS . CDC – Centre for Disease Control . SPSS – Statistical Package for the Social Sciences . FMOH – Federal Ministry of Health . PHC – Primary Health Care . PCR – Polymerase Chain Reaction . HAART – Highly Active Antiretroviral Therapy . RNA – Ribonucleic acid
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. DNA – Deoxyribonucleic acid . CI – Confidence Interval . SD – Standard Deviation . NBTS – National Blood Transfusion Service . OI – Opportunistic Infections
CHAPTER ONE
INTRODUCTION
1.1 Background to the study
Adolescents make up significant portion of any population and also form the future hope of any nation, owing to untapped resource potential. Today, almost 1 in 5 persons in the world is an adolescent, that’s 1.2 billion people between the ages 10–19 years globally.1
The state of their health is an important factor in their development as adolescents and in their maturity into adulthood.
Adolescence is a period of rapid growth and development during which an individual passes through many inter-related changes of body, mind and social relationships. The adolescent’s body grows in size, strength, stamina and reproductive capacity (soon to be a man and woman proper) and becomes more defined psychologically and emotionally.
The person becomes more capable of abstract thinking, develops more aspects of critical reasoning, morality, empathy and some remote features of future orientation and self- awareness or identity.2
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This is a period that has potential for great creativity and energy, new experiences, new ideas and opportunities. As a result, the period of adolescence is full of vulnerabilities to biological and socio-cultural problems which would further be complicated by the realities of a nation’s economy2.
While the World Health Organisation (WHO) defined ‘Adolescents’ as persons in age group 10-19 years and ‘youth’ as age group 15-24 years,3 however for the purpose of this study only the ‘Adolescent’ age group was considered.
This age group is characterized by a high tendency to engage in high risk ‘adventurous’ behaviours which includes sexual exposures that could culminate in contacting HIV or other Sexually Transmitted Infections (STIs) (with their attendant complication as well as having unwanted pregnancies).4,5 These tend to further truncate their educational pursuits, dreams and aspirations thus adversely affecting their ability to fulfil their potential and contribute to the development of their communities. Also, growing influence of electronic media, increased travel and tourism invite a change in attitude towards sexual intercourse, significantly decreased age at marriage (especially amongst rural female adolescents) and leads to relatively longer period of sexual exposure and risk of unwanted pregnancy4,5.
Adolescents remain an important group in the control of the HIV pandemic and an important target for interventions. In a behavioural survey of high risk groups for HIV, amongst the youths studied there were poor results for indicators related to HIV attitude, sexual behaviour, condom use and HIV counselling and testing in this age group.4,5 Also in a national survey, there was a low prevalence of HIV among adolescents but the
13 prevalence increased among older respondents.4,5 This makes this group an obvious target for interventions before they start adopting risky behaviours.
Young people in Nigeria constitute an important group due to their vulnerability and sexual inexperience. Even though there is a high level of awareness about HIV among young people in Nigeria, there are still relatively high levels of misconceptions and stigma.4,5 In a nationwide survey, only about a third of respondents had comprehensive knowledge about HIV while less than a quarter had accepting attitudes towards people living with HIV AIDS.4 Improvement of knowledge about HIV transmission and prevention and correction of stigma and discriminatory attitudes will help in the fight against HIV among young persons in Nigeria.
Stigma and discrimination are two major problems often faced by people living with HIV and AIDS in many developing countries, including Nigeria.4,5 Stigma and discrimination shown to persons living with and affected by HIV and AIDS can worsen the spread and the impact of the HIV and AIDS epidemic. A major contributor to this stigma and discrimination is the criminalisation of high risk groups like commercial sex workers, drug addicts/abusers and men who have sex with men (MSMs) in our society which thus drives them underground and further increase their vulnerability to HIV infection.4,5 As a result of fear of discrimination and stigma, many individuals are reluctant to seek HIV testing to know their HIV status while persons living with HIV and AIDS (PLWHAs) may be less inclined to declare and openly acknowledge their HIV sero-status. This can lead to continued under-reporting of the epidemic, increased transmission, and limited access to treatment, care and support programmes. On the other hand, stigma and
14 discrimination violate the human rights and dignity of people living with HIV and AIDS and those affected by the epidemic.4,5
Definition of Terms
Adolescents: Individuals who are within the age range of 10-19 years.3
Stigma: a distinguishing mark of social disgrace.6
Risk Perception: The subjective judgement that people make about the characteristics and severity of a risk.7
Risk Behaviour: Specific forms of behaviour which are proven to be associated with increased susceptibility to a specific disease or ill-health.8
Health Education: This is any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes.9
Sero-status: The state of either having or not having detectable antibodies against a specific antigen, as measured by a blood test (serologic test). For instance as regards
HIV, seropositive means that a person has detectable antibodies to HIV; seronegative means that a person does not have detectable HIV antibodies.10
Anti-retroviral Drugs: Medications that inhibit the reproduction of retroviruses (viruses composed of RNA rather than DNA) e.g. HIV.11
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1.2 Problem Statement
HIV/AIDS is already a global pandemic with the disease burden mainly in sub-Saharan
Africa and though it presently has no cure, with the advent of quality anti-retroviral drugs, HIV positive individuals can now have access to proper care and support that would afford them opportunity to live healthy lives and fulfil their aspirations in life.12
The benefits of these anti-retroviral therapy are best harnessed when treatment is started early in those positive for HIV before they progress into full blown AIDS (i.e. when individuals seek to know their HIV status by going for HIV counselling and testing and commence treatment upon testing positive for the virus).12 Prevention still remains the best means to control the spread of HIV/AIDS in any community and behavioural modification (to curtail risky behaviours) is at the core of achieving this especially amongst vulnerable groups like adolescents.4,5,12
The global trend in the HIV burden is that of a significant increase in the number of people living with HIV as more people are able to access the life-saving antiretroviral therapy than in previous years.12,13 Globally, it is estimated that at the end of 2014, about
36.9 million people are living with HIV;14 this represents an increase from about 34 million people as at 2012 including 3.4 million children less than 15 years.15 The HIV
16 pandemic has continued to ravage several communities in sub-Saharan Africa. There has been a multi-sectorial response to the fight against HIV in Nigeria where about 3.4 million people are living with the disease as at end of 201414 and this represents a decline from 3.5 million people with the disease as at 2012.15 The HIV prevalence has declined among young people aged 15-24 years from 6% in 2001 to 4.3% in 2005, 4.2% in 2008 and 4.1% in 201015 whilst the prevalence for adolescents aged 15-19 years was 2.9% as at
2012.14
Over the last decade, the amount of HIV new infections has declined globally to 2.0 million as at end of 2014,12 which was a reduction from 2.3 million as at Dec. 2012 (from
3.4 million in 2001) but in spite of this development, sub-Saharan Africa still bears the majority (70%) of the global HIV/AIDS burden.12,13 In Nigeria, it is estimated that
227,518 new HIV infections occurred in 2014 (male 103,917 and female 123,601).14
Likewise, the number of AIDS mortality has declined over the years with an estimated
1.2 million AIDS death globally in 201412 which was less than 1.6 million AIDS death in
2012 (as against 2.3 million in 2005) and the majority of these deaths (70%) still occurred in sub-Saharan Africa.13 In Nigeria, although the national median prevalence of HIV has taken a downward turn in recent years, the absolute number of people living with HIV has increased by almost half a million people in three years as at 2012 and AIDS related mortality has also slightly increased in the same time period to about 217,148 annual deaths attributed to AIDS.15 This trend has however changed in more recent years and since 2012, there has been a consistent decrease in AIDS related deaths as a total of
174,253 died from AIDS related cases in 2014 which is lower than 210,031 people in
2013.14 In 2007 national survey, findings revealed that peak HIV prevalence was highest
17 among the 30-39 years age group (5.4%) and lowest among the 15-19 years age group
(1.7%).4 This pattern were also reported in more recent national surveys in which the peak HIV prevalence was highest among 35-39 years age group (4.4%) and lowest among the 15-19 years group (2.9%).5,14 Preventing the spread of HIV/AIDS depends largely on influencing people to change their behaviour more so that about 80 per cent of modes of transmission remain unprotected sex with an infected partner.5,13,14
HIV/AIDS-related stigma and discrimination remains a major hindrance to knowing one’s HIV status as well as accessing care if positive,4,5,14 and remains one of the key drivers of the HIV epidemic in Nigeria which also include low personal risk perception
(which is very common amongst adolescents) and multiple concurrent sexual partnerships.4,14
1.3 Justification
Adolescents constitute a significant portion of the potentially economically productive group in any community hence the need to assess and intervene in their knowledge, attitude and behaviour towards HIV/AIDS related issues. More so that adolescents form a major part of the vulnerable group in HIV transmission.1In 2007 national survey, findings revealed that peak HIV prevalence was highest among the 30-39 years age group (5.4%) and lowest among the 15-19 years age group (1.7%),4 also, this pattern was similar to the findings in a more recent national survey in which the peak HIV prevalence was highest among 35-39 years age group (4.4%) and lowest among the 15-19 years group (2.9%).5,14 hence it remains a good opportunity to strive to halt the trend of HIV infection by
18 intervening at the adolescent age group before they are more likely to contract the virus owing to their propensity for experimentation with risky behaviours as well as stigmatisation and discriminatory attitudes towards those already HIV positive.
The number of AIDS death in Nigeria is still very significant despite the fact that in very recent years, there have been a steady decline in the absolute number of AIDS related deaths in the country (A total of 174,253 died from AIDS related cases in 2014 which is lower than 210,031 people in 2013).14 In spite of the increase in availability of HIV
Counselling and Testing (HCT) services in the country, most individuals have never presented themselves to be tested even when they knew where to go for a HIV test as observed in a recent national survey where only about 13% of adolescents aged 15-19 years reported to have ever tested for HIV.5,14 As a result of fear of discrimination and stigma, many individuals are afraid of seeking HIV testing to know their HIV status while persons living with HIV and AIDS (PLWHAs) may be less inclined to declare and openly acknowledge their HIV sero-status which can lead to continued under-reporting of the epidemic, increased transmission, and limited access to treatment, care and support programmes. Thus stigma in addition to high risk behaviours (e.g. sex without condom use) remain part of the key drivers of the HIV/AIDS epidemic in Nigeria even in spite of increased awareness about HIV/AIDS.4,5,14
This notwithstanding, there has not been any study that quantifies the burden of effect of stigma and discrimination on access to care of HIV in Nigeria. Hence there is need for intervention studies on the adolescents that would focus on their development of accepting attitudes to people living with HIV/AIDS (PLWHAs).
19
There is generally an increased awareness about HIV/AIDS among adolescents in
Nigeria as evidenced by findings from recent national surveys,4,5 however, there still exist several misconceptions concerning HIV/AIDS in terms of its modes of transmission as well as prevention. These have culminated in these adolescents having low perception about their risk of contracting the virus hence their propensity to engaging in risky behaviours.4,5 In a nationwide survey, in spite of most respondents having heard of HIV
AIDS, significant misconceptions still existed for example, more than 30 per cent of adolescents 15-19 years knew that AIDS had no cure;5 while more than half of these adolescent respondents felt they had no risk of being infected with HIV (no self-risk perception of HIV),5 while less than half had accepting attitudes towards people living with HIV AIDS.5 There is therefore need to institute measures to address the gap in the knowledge/awareness about HIV/AIDS and the risky behaviours still prevalent among vulnerable groups like the adolescents as well as the high stigma and discrimination against people living with HIV/AIDS if there would be any meaningful improvement in the burden of the disease in the country which at present may well be grossly under- reported.
In Ogun State, in spite of the efforts of line ministries such as the Ministry of Education
(in collaboration with the State Ministry of Health and partners) to train the teachers in public secondary schools on Family Life and HIV Education (FLHE), this is yet to be fully integrated into the school curriculum hence the gap remains in the knowledge, attitude as well as behaviours of the in-school adolescents regarding HIV related issues and by extension also affects adolescents who are not in school as they would not be positively influenced by their peers who are still in school.16
20
Hence this research was intended as an intervention study on adolescents in which health education on risky behaviours as well as stigmatisation attitudes (against HIV/AIDS positive individuals in their communities) was instituted on some of them and its effect on these adolescents was compared with those in the control group. The outcome of this research is firmly believed would help in planning proper interventions to bridge the gaps in knowledge and behaviour already existing among adolescents as well as stem the tide in stigmatisation against people living with HIV/AIDS in Nigeria even as the country seeks to end the AIDS epidemic by 2030.17
1.4 Objectives of the study a) Broad Objective:
To determine the effect of health education on HIV/AIDS risk behaviours and stigmatization attitudes among adolescents in Ogun State, Nigeria.
b) Specific Objectives:
1. To determine the HIV risk behaviours of adolescents in Ogun State.
2. To determine the awareness and stigmatizing attitudes against HIV positive
individuals by the adolescents in Ogun State.
3. To identify factors influencing risk behaviours and stigmatization amongst the adolescents in Ogun State.
21
4. To institute health education intervention to the adolescents in Ogun State on HIV
risk behaviours and stigmatization attitudes against HIV positive individuals.
5. To determine the effect of health education on the risk behaviours and
stigmatization attitudes engaged upon by the adolescents in Ogun State.
1.5 Scope and Focus of the Study
This was a community-based study conducted on adolescents within age range 10-19 years (in or out of school) in Ogun State, Nigeria. It sought to determine the risk behaviours (as relates to HIV/AIDS) engaged upon by these adolescents as well as their awareness and attitudes of stigmatisation and discrimination against HIV positive individuals in their communities.
There was also the institution of health education intervention on some of the adolescents involved in the study to determine the effect of this on their risk behaviours as well as their stigmatisation attitudes (against HIV positive individuals) and the outcome compared with those of the control group.
To strengthen generalizability of the findings from this study in Ogun State, two Local
Governments were involved in which one served as the intervention group whilst the other was the control.
HYPOTHESES:
22 a) Null Hypothesis 1 (H01): if a health education intervention was instituted on
adolescents in Ogun State, there will be no improvement in their risk perception
about HIV/AIDS. b) Null Hypothesis 2 (H02): if a health education intervention was instituted on
adolescents in Ogun State, there will be no effect on their risky behaviours as
relates to HIV/AIDS. c) Null Hypothesis 3 (H03): if a health education intervention was instituted on
adolescents in Ogun State, there will be no effect on their stigmatisation attitudes
against HIV positive individuals in their community. d) Alternative Hypothesis 1 (HA1): if a health education intervention was instituted
on adolescents in Ogun State, there will be improvement in their risk perception
about HIV/AIDS. e) Alternative Hypothesis 2 (HA2): if a health education intervention was instituted
on adolescents in Ogun State, there will be positive effect (improvement) on their
risky behaviours as relates to HIV/AIDS. f) Alternative Hypothesis 3 (HA3): if a health education intervention was instituted
on adolescents in Ogun State, there will be positive effect (improvement) on their
stigmatisation attitudes against HIV positive individuals in their community.
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CHAPTER TWO
LITERATURE REVIEW
2.1 EPIDEMIOLOGY OF HIV/AIDS
Globally, an estimated 36.9 million people were living with HIV worldwide as at end of
2014,12 compared with 35.3 million people as at Dec. 2012 which represents an increase from previous years as more people are receiving the life-saving antiretroviral therapy.12;
13 Also, there were 2.0 million new HIV infections globally at end of 2014, showing over
33% decline in the number of new infections from 3.4 million in 2001 but sub-Saharan
Africa still bears the majority (about 70 per cent) of the global burden.12 At the same time the number of AIDS deaths is also declining with an estimated 1.2 million AIDS deaths in end of 2014, down from 2.3 million in 2005 and 1.6 million in 2012; of these deaths over 70 per cent are from Sub Saharan Africa.12
24
Sub-Saharan Africa remains the most seriously affected region, with AIDS remaining the leading cause of death there.13; 18 AIDS remains a leading cause of mortality worldwide and the primary cause of death in Sub-Saharan Africa, illustrating the tremendous, long term challenge that lies ahead for provision of treatment services, with the hugely disproportionate impact on Sub-Saharan Africa ever clearer.13; 18
Global HIV incidence likely peaked in the late 1990s at over 3 million new infections per year and was estimated to be 2.5 million new infections in 2007 of which over two thirds
(68 per cent) occurred in Sub-Saharan Africa;13 this further reduced to 2.3 million as at
201213 and later declined to 2.0 million as at end of 2014.12 This reduction in HIV incidence likely reflects natural trends in the epidemic as well as the result of prevention programmes resulting in behavioural change in different contexts.12; 13; 18
Regional data indicate that Sub-Saharan Africa continues to be the region most affected by the AIDS epidemic.12 More than two of three (68 per cent) adults and nearly 90 per cent of children infected with HIV live in this region, and more than 70 per cent of AIDS deaths in 2012 occurred there, illustrating the unmet need for treatment in Africa.13 The region’s epidemics, however, vary significantly in the scale, with national adult (15-49 years) HIV prevalence ranging from less than 2 per cent in some countries of the Sahel to above 15 per cent in most of southern Africa. Southern Africa alone accounted for almost one third (32 per cent) of all new infections and AIDS deaths globally.13
In Nigeria, since the first case was reported in 1986, there has been a steady increase in the national prevalence of the HIV infection owing largely to increased sentinel surveillance for the virus.4; 5 From about 1.8 per cent in 1991, it increased to 3.8 per cent
25 two years later reaching a peak in 2001 (5.8 per cent) before declining gradually in 2003
(5.0 per cent) and 2005 (4.4 per cent).19 This was followed by a rise to 4.6 per cent in
2008 and then a recent decline to 4.1 per cent in 2010.15 Nigeria was among the 26 countries globally that experienced a 50 per cent decline in adult HIV incidence between
2001 and 2012;13 also the HIV prevalence among young people aged 15 - 49 years declined from 3.5 per cent in 2001 to 3.1 per cent in 2012 while new infections in all ages also reduced from an estimated 400,000 in 2001 to about 260,000 in 2012.13 Recent data released by the Federal Government indicate that as at December 2014 Nigeria now has
HIV prevalence rate of 3.4 per cent (about 3.4 million people living with HIV) and is now the second largest HIV burden globally, with Rivers State having a prevalence rate of 15.2 per cent which is now the highest in the country, whilst Ogun State has one of the least rates being 0.6 per cent.14; 17 AIDS related deaths which had hitherto increased in
Nigeria from an estimated 150,000 in 2001 to 240,000 in 201213 had witnessed steady decline in subsequent years from 210,031 in 2013 to 174,253 as at end of 2014.14
One of the earliest national responses to the HIV/AIDS epidemic in Nigeria was the setting up of a surveillance system to determine the magnitude of the HIV problem, as well as monitor trends of the epidemic.4; 5; 14 The surveillance involved prevalence rates for HIV and syphilis among various groups such as women attending antenatal clinics, blood donors, transport workers and patients attending sexually transmitted Infection
(STI) and tuberculosis (TB) clinics.4; 5; 14 Later, behavioural surveillance survey was added on a larger scale to determine and monitor the knowledge, attitudes and behaviour associated with HIV and STI infections among the general population and selected groups of interest.4; 5; 14
26
There is an increased government and donor emphasis on effective interventions for the prevention, care and mitigation of the impact of HIV and AIDS and sexually transmitted infections (STI) on the population. This has led to demand for current and accurate biomarkers to monitor progress.14; 15 For HIV programs, these biomarkers would be those associated with sexual transmission (sexually transmitted infections) or parenteral transmission of HIV (blood borne infections).14; 15 In countries with generalized epidemics, it is recognized that some population sub-groups contribute disproportionately to the STI and HIV/AIDS epidemics.14; 15 The need to design programs that target these groups has long been recognized. Consequently, repeated cross-sectional behavioural and biologic data collections have been carried out in several countries to monitor trends and evaluate such programs.14; 15
In Ogun State, the prevalence rate of HIV/AIDS has fluctuated over the years with 2.5 per cent in 1999, 3.5 per cent in 2001 and 1.5 per cent in 2003.16; 20 This figure went up again to 3.6 per cent in 2005 and down to 1.7 per cent in 2008 and increased to 3.1 per cent in 201016; 20 and most recent data however reveals a marked reduction in the HIV prevalence in the State which as at 2014 is 0.6%14; 17 which represents an estimated 150,
000 persons living with HIV and AIDS in the State.16; 20 There are also wide variations in
HIV prevalence between communities (for example 5 per cent in Ijebu Ode and 1.3 per cent in Ayetoro) and an apparently higher prevalence in urban sites than in rural sites which perhaps underscores the gross under-reporting occasioned by inhibitions associated with stigma and discrimination.20
27
Key drivers of the HIV epidemic in the State as in other parts of the country include poverty, low literacy level, stigma and discrimination low use of condom and risky sexual behaviours.16
2.2 VIROLOGY AND TRANSMISSION OF HIV
HIV is the cause of the spectrum of disease known as HIV/AIDS. HIV is a retrovirus that primarily infects components of the human immune system such as CD4+ T cells, macrophages and dendritic cells. It directly and indirectly destroys CD4+ T cells.21
HIV is a member of the genus Lentivirus,21 part of the family Retroviridae.21 Lentiviruses are transmitted as single-stranded, positive-sense, enveloped RNA viruses. Upon entry into the target cell, the viral RNA genome is converted (reverse transcribed) into double- stranded DNA by a virally encoded reverse transcriptase that is transported along with the viral genome in the virus particle. The resulting viral DNA is then imported into the cell nucleus and integrated into the cellular DNA by a virally encoded integrase enzyme and host co-factors.22 Once integrated, the virus may become latent, allowing the virus and its host cell to avoid detection by the immune system.22 Alternatively, the virus may be transcribed, producing new RNA genomes and viral proteins that are packaged and released from the cell as new virus particles that begin the replication cycle anew.22
Two types of HIV have been characterized: HIV-1 and HIV-2. HIV-1 is the virus that was originally discovered (and initially referred to also as LAV or HTLV-III). It is more virulent, more infective,23 and is the cause of the majority of HIV infections globally. The lower infectivity of HIV-2 as compared with HIV-1 implies that fewer people exposed to
28
HIV-2 will be infected per exposure. Because of its relatively poor capacity for transmission, HIV-2 is largely confined to West Africa.24
HIV is transmitted by three main routes: sexual contact, exposure to infected body fluids or tissues and from mother to child during pregnancy, delivery, or breastfeeding (known as vertical transmission).25 There is no risk of acquiring HIV if exposed to faeces, nasal secretions, saliva, sputum, sweat, tears, urine, or vomit unless these are contaminated with blood.25 It is possible to be co-infected by more than one strain of HIV—a condition known as HIV superinfection.25
a) Sexual
The most frequent mode of transmission of HIV is through sexual contact with an infected person.25 The majority of all transmissions worldwide occur through heterosexual contacts (i.e. sexual contacts between people of the opposite sex);25 however, the pattern of transmission varies significantly among countries.
As regards unprotected heterosexual contacts, estimates of the risk of HIV transmission per sexual act appear to be four to ten times higher in low-income countries than in high- income countries.25 In low-income countries, the risk of female-to-male transmission is estimated as 0.38% per act, and of male-to-female transmission as 0.30% per act; the equivalent estimates for high-income countries are 0.04% per act for female-to-male
29 transmission, and 0.08% per act for male-to-female transmission.25 The risk of transmission from anal intercourse is especially high, estimated as 1.4–1.7% per act in both heterosexual and homosexual contacts.25; 26 While the risk of transmission from oral sex is relatively low, it is still present.27 The risk from receiving oral sex has been described as "nearly nil"27 however a few cases have been reported.27 The per-act risk is estimated at 0–0.04% for receptive oral intercourse.27 In settings involving prostitution in low income countries, risk of female-to-male transmission has been estimated as 2.4% per act and male-to-female transmission as 0.05% per act.25
Risk of transmission increases in the presence of many sexually transmitted infections28 and genital ulcers.25 Genital ulcers appear to increase the risk approximately fivefold.25
Other sexually transmitted infections, such as gonorrhoea, chlamydia, trichomoniasis, and bacterial vaginosis, are associated with somewhat smaller increases in risk of transmission.27
The viral load of an infected person is an important risk factor in both sexual and mother- to-child transmission.29 During the first 2.5 months of an HIV infection a person's infectiousness is twelve times higher due to this high viral load.27 If the person is in the late stages of infection, rates of transmission are approximately eightfold greater.25
Commercial sex workers (including those in pornography) have an increased rate of
HIV.30 Rough sex can be a factor associated with an increased risk of transmission30.
Sexual assault is also believed to carry an increased risk of HIV transmission as condoms are rarely worn, physical trauma to the vagina or rectum is likely, and there may be a greater risk of concurrent sexually transmitted infections.31
30 b) Body fluids
The second most frequent mode of HIV transmission is via blood and blood products.25
Blood-borne transmission can be through needle-sharing during intravenous drug use, needle stick injury, transfusion of contaminated blood or blood product, or medical injections with unsterilised equipment. The risk from sharing a needle during drug injection is between 0.63 and 2.4% per act, with an average of 0.8%.90 The risk of acquiring HIV from a needle stick from an HIV-infected person is estimated as 0.3%
(about 1 in 333) per act and the risk following mucus membrane exposure to infected blood as 0.09% (about 1 in 1000) per act.25 HIV is transmitted in about 93% of blood transfusions involving infected blood.31 In developed countries the risk of acquiring HIV from a blood transfusion is extremely low (less than one in half a million) where improved donor selection and HIV screening is performed;25 for example, in the UK the risk is reported at one in five million.32 In low income countries, only half of transfusions may be appropriately screened (as of 2008),33 and it is estimated that up to 15% of HIV infections in these areas come from transfusion of infected blood and blood products, representing between 5% and 10% of global infections.25
Unsafe medical injections play a significant role in HIV spread in sub-Saharan Africa. In
2007, between 12 and 17% of infections in this region were attributed to medical syringe use.33 The World Health Organisation estimates the risk of transmission as a result of a medical injection in Africa at 1.2%.33 Significant risks are also associated with invasive procedures, assisted delivery, and dental care in this area of the world.33
31
People giving or receiving tattoos, piercings, and scarification are theoretically at risk of infection but no confirmed cases have been documented.33 It is not possible for mosquitoes or other insects to transmit HIV.34 c) Mother-to-child
HIV can be transmitted from mother to child during pregnancy, during delivery, or through breast milk.35 This is the third most common way in which HIV is transmitted globally.25 In the absence of treatment, the risk of transmission before or during birth is around 20% and in those who also breastfeed 35%.32 As of 2008, vertical transmission accounted for about 90% of cases of HIV in children.35 With appropriate treatment the risk of mother-to-child infection can be reduced to about 1%.35 If blood contaminates food during pre-chewing it may pose a risk of transmission.33
2.3 HIV/AIDS KNOWLEDGE AND ATTITUDE
Earlier studies at the turn of the millennium revealed that there were generally poor knowledge and awareness about HIV/AIDS among adolescents in Nigeria.36-39 These included their lack of adequate knowledge of the full meaning of HIV and AIDS;36; 37 also about the modes of transmission of the virus like blood transfusion, mother-to-child
(vertical) transmission as well as intravenous drug use (they showed relatively higher knowledge of sexual intercourse as a means of contracting HIV).36-39 In a particular study of in-school adolescents, it was discovered that despite there being a poor knowledge of
HIV/AIDS generally, students from Federal school demonstrated more knowledge than students from State and private schools.38 Similarly, students from all-male school had
32 more knowledge than students from all-female and co-educational schools. Students from high social class demonstrated more knowledge than those from middle and low social class.5 There was also poor awareness that AIDS has no cure.36-39
More recent studies in the last few years however showed that there have been a significant improvement in the knowledge and awareness of adolescents about
HIV/AIDS as almost all the adolescents were aware of HIV/AIDS and had a better knowledge about HIV/AIDS.4; 5; 40-46 However, several misconceptions still exist concerning HIV/AIDS which include that HIV can be contracted through sharing of toilet with an infected person,4; 5 through mosquito bite,4; 5; 47 through sharing meals with an infected person;4; 5 HIV can be prevented by using antibiotics,4; 5 by simply praying to
God;4; 5 also, many adolescents were not aware that a healthy looking individual could be
HIV positive.4; 5; 47 Hence interventions are needed to bridge the identified gaps in knowledge about HIV/AIDS. In this regard, there is a continual need for the design and implementation of a comprehensive and culturally appropriate HIV/AIDS and sexual health program for adolescents in Nigeria which meets their needs.14; 15
Various intervention approaches had been adopted which include health education especially Family Life Health Education (FLHE) using the teachers of in-school adolescents,43; 44; 46; 48-52 and peer education.45; 53; 54 There were generally significant improvement in the knowledge of HIV/AIDS (and other reproductive health issues) among the adolescents following intervention. Family Life Health Education (FLHE) as an intervention strategy is however not without its own challenges as shown in various studies in several developing countries especially in Africa where it had been adopted.55
These challenges include: high level of knowledge about HIV/AIDS among teachers but
33 poor transfer of same to the intended student targets due to cultural and social inhibitions;49 teachers in other instances not receiving adequate training and motivation on information, education and communication for HIV/AIDS;49 large class sizes;50 too many activities in the intervention;50 teachers resistance to and inexperience in using participatory methods;50 high teacher turnover i.e. trained teachers being frequently redeployed away from the school in which they were originally trained to render the service;50 it is heavily dependent on the teachers’ level of confidence in teaching
HIV/AIDS and sexuality in schools.52
The level of confidence of the teachers could be affected by several factors including: number of years teaching HIV/AIDS and sexuality;52 formal training in these subjects;52 individual’s experience in discussing the topic with others;52 school policy and priority given to teaching HIV/AIDS and sexuality at school.52 Hence all these have to be considered to ensure that teachers’ confidence is strengthened before adopting FLHE as an intervention strategy.
In a particular study in a rural community in south-west Nigeria, students in four schools were randomized to four treatment arms: teacher instructions alone, peer education alone, combination of teacher instruction and peer education and control.46 The three intervention groups had significant knowledge gains compared with the control group.46
Overall the school with the combined intervention had greater knowledge compared to the other groups.46 The study concluded that multiple intervention strategies are more effective in improving reproductive health knowledge of adolescents.46 Another intervention study sought to determine the impact of health education on the reproductive health knowledge of adolescents in a rural south-east Nigerian community,51 it was a pre-
34 post test study design that compared adolescents in a secondary school (study group), which received health education on reproductive health with another secondary school
(control group), which did not receive any. The research instrument was also applied 6 weeks later in both groups to check for any residual gain in knowledge and it was discovered that there was a significant gain in knowledge among the intervention group compared with the control group.51
2.4 SEXUAL BEHAVIOUR
The adolescent age group is characterised by a high tendency to engage in high risk
‘adventurous’ behaviours which includes sexual exposures that could culminate in contacting HIV or other Sexually Transmitted Infections (STIs) (with their attendant complication as well as having unwanted pregnancies).4; 5
Sexual intercourse (heterosexual transmission) remain the most common mode of transmission of HIV;4; 5; and it was found to be the mode of transmission most known to the adolescent respondents in two national surveys.4; 5
Several studies in Nigeria (and other African countries) have found that the median age of sexual debut for the adolescent age group range from as low as 12yrs to as high as
19yrs.4; 5; 40; 44; 51; 54; 56-63 The circumstances that led to sexual debut include mutual agreement, coercion and curiosity.58 Despite a very high awareness about HIV/AIDS
(including other STIs) among the adolescents, this has not significantly influenced them to have good sexual practices.4;40; 42; 43; 51; 54; 56; 57- 63 In a national survey, it was discovered a significant proportion of the adolescent respondents had ever engaged in sex and that
35 the proportion of female adolescents that had engaged in sex was double (43 per cent) that of the males (22 per cent);4 a similar pattern was found in a more recent national survey in which 37 per cent of the females as compared with 17 per cent male adolescent respondents had ever had sex5; with majority of them having engaged in sexual activity within the last 12 months preceding the survey.4;5 A significant proportion of the sexually active adolescents were found to have multiple non-marital sexual partners with the males having more partners than the females.4; 5 These findings have been corroborated in various studies.40-42; 56-59; 64 Heterosexual intercourse is the most common type of sexual activity engaged by the adolescents.4; 5; 40; 42; 64
A cross-sectional descriptive study of in-school adolescents in Ibadan, south-west Nigeria on their perception about sexual abstinence and prevention of HIV/AIDS found that less males were abstaining from sex compared with the females.56 The study identified major significant predictors of sexual abstinence such as being a female, not having a boyfriend or girlfriend, not using alcohol and having a positive attitude towards abstinence.56
Sexual abstinence was also significantly associated with perceived self-efficacy to refuse sex and negative perception of peers who engage in sexual behaviours.56 The study concluded that since multiple factors influence sexual abstinence behaviours among adolescents, these should be considered in determining the effectiveness of interventions targeting this behaviour;56 hence coherent sexuality education interventions to promote the adoption of abstinence among young people were urgently needed.56
The findings in the above study were corroborated by findings in an interventional study to know the impact of health education on sexual risky behaviours among senior secondary students in Jos, Nigeria65 in which the sexual behaviours of students in the
36 intervention group were assessed at baseline and after they were given HIV/AIDS health education, these were re-assessed after 6 months and the findings compared with those of students in the control group (from other similar schools).65 It was found that students who lived in urban areas and those who lived with both parents were less likely to have experienced sexual intercourse at baseline than those who lived in the rural areas (but school in Jos during school sessions), and those who lived with single parents and other relations.65 Health education delayed sexual debut among students who were sexually naïve but had no effect on the sexual activity of those who were already sexually experienced.65 The study thus concluded that health education intervention had a place in reducing secondary school students' sexual risk behaviour if commenced before their sexual debut.65
There is generally good knowledge of use of condom as a means of prevention of HIV
(and other STIs) but this has not translated in its regular and consistent use by the sexually active adolescents.4; 5; 40-42; 57; 64 In two national surveys, it was found that though condom use was higher among male adolescents, its use is still poor generally in both sexes.4; 5 Reasons for condom use included prevention of unwanted pregnancies and protection against HIV/STIs;4; 5 in contrast, reasons given by the adolescent respondents
(who hitherto were using condoms) for stopping to use condoms during sexual intercourse were mainly that they did not enjoy using condoms and that their partners opposed to its use.4; 5 In a cross-sectional population survey of 300 male and female secondary school students within the age group of 13-19 years in Ilesha, south-west
Nigeria, the sexual behaviour and contraceptive use among these teenage secondary school students were investigated.58 It was found that a predominant proportion of the
37 sexually active adolescents did not use any contraception at first coitus and most of them had multiple sexual partners.58
The above sexual behaviours are not unconnected with the risk perception of the adolescents as relates to HIV/AIDS which is generally poor among this age group as typified in the findings in a national survey in which majority of the adolescent respondents were of the opinion that they had no risk at all of contracting HIV4 and in a more recent national survey, there was no significant change as this perception was still shared by over half of the adolescent respondents.5 This finding was corroborated by another study of secondary school adolescents majority of whom had multiple sexual partners yet had poor perception of the risk of contracting sexually transmitted infections
(STIs).59
In the light of the discrepancies shown between knowledge on HIV/AIDS and sexual practices, a study to determine the effect of sex education programme on at-risk sexual behaviour of school-going adolescents in Ilorin, Nigeria64 recommended that an all- inclusive approach to AIDS campaign including education and encounters that heightens the perception of seriousness and concern about AIDS epidemics could facilitate improved sexual practices and behaviour among the adolescents.64
Various adolescents’ sexual behaviour intervention studies had been conducted in Nigeria and there were significant improvements in their risky behaviours following intervention.
The findings include decrease in the number of sexual partners;51; 66 rejection of myths, attitudes related to abstinence and condom use;43
38
2.5 HIV/AIDS AND DRUG ABUSE AND ADDICTION
Drug abuse and addiction have been linked with HIV/AIDS since the beginning of the epidemic. This is partly due to the addictive and intoxicating effects of many drugs, which can alter judgment and inhibition and lead people to engage in impulsive and unsafe behaviours that increase their vulnerability to contracting HIV.67; 68
People typically associate drug abuse and HIV/AIDS with injection drug use and needle sharing. When injection drug users share items such as needles, syringes, and other drug injection paraphernalia HIV can be transmitted between users. However, drug abuse by any route (not just injection) can put a person at risk for getting HIV as drug and alcohol intoxication affect judgment and can lead to unsafe sexual practices, which put people at risk for getting HIV or transmitting it to someone else.69
Drug abuse and addiction can affect a person's overall health, thereby altering susceptibility to HIV and progression of AIDS.69 Drugs of abuse and HIV both affect the brain as research has shown that HIV causes greater injury to cells in the brain and cognitive impairment among methamphetamine abusers than among HIV patients who do not abuse drugs. In animal studies, methamphetamine has been shown to increase the amount of HIV in brain cells.70
Since the late 1980s, research has shown that treating drug abuse is an effective way to prevent the spread of HIV.71 Drug abusers on treatment stop or reduce their drug use and related risk behaviours, including drug injection and unsafe sexual practices.71
39
2.6 STIGMA & DISCRIMINATION ASSOCIATED WITH HIV/AIDS
Stigma can be defined as “a distinguishing mark of social disgrace”.6 People living with
HIV and AIDS (PLWHAs) often face stigma and discrimination, especially in developing countries.13
AIDS stigma exists around the world in a variety of ways, including ostracism, rejection, discrimination and avoidance of HIV infected people; compulsory HIV testing without prior consent or protection of confidentiality; 72 violence against HIV infected individuals or people who are perceived to be infected with HIV; and the quarantine of HIV infected individuals.72 Stigma-related violence or the fear of violence prevents many people from seeking HIV testing, returning for their results, or securing treatment, possibly turning what could be a manageable chronic illness into a death sentence and perpetuating the spread of HIV.73
AIDS stigma has been further divided into the following three categories:
Instrumental AIDS stigma—a reflection of the fear and apprehension that are
likely to be associated with any deadly and transmissible illness.74
Symbolic AIDS stigma—the use of HIV/AIDS to express attitudes toward the
social groups or lifestyles perceived to be associated with the disease.74
Courtesy AIDS stigma—stigmatization of people connected to the issue of
HIV/AIDS or HIV-positive people.75
40
Often, AIDS stigma is expressed in conjunction with one or more other stigmas, particularly those associated with homosexuality, bisexuality, promiscuity, prostitution, and intravenous drug use.76
In many developed countries, there is an association between AIDS and homosexuality or bisexuality, and this association is correlated with higher levels of sexual prejudice, such as anti-homosexual/bisexual attitudes.76 There is also a perceived association between
AIDS and all male-male sexual behaviour, including sex between uninfected men.74
However, the dominant mode of spread worldwide for HIV remains heterosexual transmission.77
In 2003, as part of an overall reform of marriage and population legislation, it became legal for people with AIDS to marry in China.78 The accepting attitudes towards persons living with HIV or AIDS include responses to some stigma and discrimination issues.6
Stigma remains a major hindrance to knowing one’s HIV status as well as accessing care if positive.4; 5 Concerning adolescents, a national survey revealed that in spite of the adolescents having a fair knowledge of where to get tested for HIV in their community, almost all of them had never been tested for HIV though majority expressed desire to get tested just to know their status.4; 5
2.7 STIGMA AND DISCRIMINATION REDUCTION
Programmes aimed at reducing stigma and discrimination against people living with HIV or people at risk of HIV infection should address the actionable causes of stigma and discrimination and empower people living with and vulnerable to HIV.79 Research has
41 shown that the actionable causes are: (a) ignorance about the harm of stigma, (b) continuing irrational fears of infection, and (c) moral judgement.79; 80 In a cross-sectional study to assess the attitude of antenatal attendees to people living with HIV/AIDS
(PLWHAs) in Uyo, south-south Nigeria,81 it was found that there was a statistically significant association between good knowledge of HIV/AIDS and a positive attitude to
PLWHAs and a high educational status with a positive attitude to PLWHAs.81 The study thus concluded that specific information and counselling interventions aimed at dispelling misconceptions about HIV/AIDS should be reinforced.81
Programmes to address these causes can involve a variety of approaches, including:
Community interaction and focus group discussions involving people living with
HIV and members of populations vulnerable to HIV infection;79; 80 as reinforced
in a study that concluded that education intervention was associated with
increased accepting attitudes to people living with HIV/AIDS (PLWHAs).61
Use of media, including advertising campaigns, entertainment designed to educate
as well as to amuse (“edutainment”), and integration of non-stigmatizing
messages into TV and radio shows;79 this was reinforced by a Nigerian-based
study to assess the relationship between media saturation, communication
exposure and HIV stigma in Nigeria and found that accepting attitudes towards
people living with HIV were more prevalent among men than among women.82
Exposure to HIV-related communication on the media was associated with
increased knowledge about HIV, which is in turn a strong predictor of accepting
attitudes.82 Communication exposure also had a significant and positive
42
association with accepting attitudes towards people living with HIV.82 In contrast,
community media saturation was not strongly linked with accepting attitudes for
either sex.82 The findings strongly suggest that media-based HIV programs
constitute an effective strategy to combat HIV/AIDS-related stigma and should
therefore be intensified in Nigeria.77
Engagement with religious and community leaders, and celebrities;75
Inclusion of non-discrimination as part of institutional and workplace policies in
employment and educational settings;75
Measurement of HIV-related stigma through the People Living with HIV Stigma
Index,78 including in health care settings and communities; and
Peer mobilization and support developed for and by people living with HIV aimed
at promoting health, well-being and human rights.79; 80
In two national surveys, it was found that majority of the adolescent respondents (who had heard of AIDS) indicated their willingness to care for both male and female family members who were HIV positive however, a little over half of them would still prefer keeping AIDS in the family a secret.4; 5 Furthermore, in assessing their attitude towards non-family members who were HIV positive, less than half of them indicated their willingness to share meals with an HIV positive person;4; 5 while there was poor response as regards willingness to buy food from an HIV positive food-seller which connote serious stigma and discrimination burden still a reality associated with HIV/AIDS in
Nigeria.4; 5
In a cross-sectional study to identify barriers to accessing PMTCT services by women attending antenatal clinic in a community in Benue State, Nigeria it was discovered that
43 almost half of the study participants had not done the HIV test in pregnancy mainly because of issues of stigma as well as attitudes of staff.83
In a study to assess post diagnosis reaction and perceived stigma of HIV/AIDS patients attending a treatment facility in Kano, Northern Nigeria, it was found that almost all of them were shocked, sad, angry and afraid upon knowing their HIV positive status.84 A significant portion of the respondents were discriminated against and these discriminations happened at home, in the workplace and also among friends.84 A related cross-sectional study in another northern State in Nigeria, that sought to determine factors hindering acceptance of HIV/AIDS counselling and testing (HCT) among youths, revealed that majority of the 600 youths that participated identified stigma and discrimination as one of the major factors responsible for the low patronage of HCT centres in the State.85
In Nigeria, there is a dearth of intervention studies on stigma and discrimination as relates to HIV/AIDS, more so on adolescents. A systemic review of studies on HIV/AIDS- related stigma and discrimination in Nigeria revealed that there was paucity of relevant research on stigma and discrimination related to the HIV-AIDS epidemic in Nigeria, although there was much anecdotal evidence documenting the role of stigma on individual and community participation in health related activities.86 It further concluded that stigma remained a barrier to all the essential components that make up a good HIV prevention programme, and much detailed research on stigma reduction was needed to improve the components of a good prevention programme.86
44
There are however intervention studies in other countries that sought to bridge this gap; this include a community intervention study in South Africa in which there was implementation of a comprehensive HIV stigma-reduction and wellness-enhancement community intervention that focused on people living with HIV/AIDS (PLWHAs), as well as people living close to them (PLC).87 It was discovered that the increase in knowledge about stigma, coping with it, and improved relationships led to PLWHAs feeling less stigmatized and more willing to disclose their HIV status.87 Also, PLCs became aware of their stigmatizing behaviours and were empowered to lead stigma reduction efforts in their communities.87
Similarly, in India, there was a community-based media intervention study involving key
HIV-vulnerable communities in which two HIV stigma videos were created using techniques from traditional film production and new media digital storytelling.88 A series of 16 focus group discussions were held in 4 rural and 4 urban sites in the same region of the country, with specific groups for sex workers, men who have sex with men, young married women, and others. Focus groups with viewers of the traditional film (8 focus groups, 80 participants) and viewers of the new media production (8 focus groups, 69 participants) revealed the mechanisms through which storyline, characters, and aesthetics influence viewers' attitudes and beliefs about HIV-related stigma.88 A comparative pre-
/post-survey showed that audiences of both videos significantly improved their stigma scores. It was concluded that a simple illustrated video, produced on a limited budget by amateurs, and a feature film, produced with an ample budget by professionals, elicited similar responses from audiences and similar positive short-term outcomes on stigma.88
45
A diagrammatic illustration of inter-relationship of several factors and HIV/AIDS outcome could be illustrated thus:
Uninfected Individual
- Risky behaviours/practices - Misinformation (about HIV prevention, transmission etc.) - Poor HIV risk perception - Poor attitude to HCT services
HIV Infected
Good access to care Reduced stigma & - Poor access to care discrimination Safe practices Good nutrition - Stigma & discrimination
- Poor nutrition
46
- Poor safe practices e.g. indiscriminate unprotected sexual exposures
AIDS
- Stigma & Discrimination - Poor access to care etc.
DEATH 2.8 SIGNS AND SYMPTOMS OF HIV/AIDS
There are three main stages of HIV infection: acute infection, clinical latency and
AIDS.89
Acute infection: Main symptoms of acute HIV infection
The initial period following the contraction of HIV is called acute HIV, primary HIV or acute retroviral syndrome.89 Many individuals develop an influenza-like illness or a mononucleosis-like illness 2–4 weeks post exposure while others have no significant symptoms.89 Symptoms occur in 40–90% of cases and most commonly include fever, large tender lymph nodes, throat inflammation, a rash, headache, and/or sores of the mouth and genitals.89 The rash, which occurs in 20–50% of cases, presents itself on the trunk and is maculopapular, classically.90 Some people also develop opportunistic infections at this stage.89 Gastrointestinal symptoms such as nausea, vomiting or diarrhoea may occur, as may neurological symptoms of peripheral neuropathy or
47
Guillain-Barre syndrome.91 The duration of the symptoms varies, but is usually one or two weeks.91
Clinical latency: The initial symptoms are followed by a stage called clinical latency, asymptomatic HIV, or chronic HIV.89 Without treatment, this second stage of the natural history of HIV infection can last from about three years92 to over 20 years92 (on average, about eight years).92 While typically there are few or no symptoms at first, near the end of this stage many people experience fever, weight loss, gastrointestinal problems and muscle pains.89
Main symptoms of AIDS
Acquired immunodeficiency syndrome (AIDS) is defined in terms of either a CD4+ T cell count below 200 cells per µL or the occurrence of specific diseases in association with an
HIV infection.91 In the absence of specific treatment, around half of people infected with
HIV develop AIDS within ten years.91 The most common initial conditions that alert to the presence of AIDS are pneumocystis pneumonia (40%), cachexia in the form of HIV wasting syndrome (20%) and oesophageal candidiasis.91 Other common signs include recurring respiratory tract infections.91
Opportunistic infections may be caused by bacteria, viruses, fungi and parasites that are normally controlled by the immune system.93 Which infections occur partly depends on what organisms are common in the person's environment.91 These infections may affect nearly every organ system.94
48
People with AIDS have an increased risk of developing various viral induced cancers including Kaposi's sarcoma, Burkitt's lymphoma, primary central nervous system lymphoma, and cervical cancer.90 Kaposi's sarcoma is the most common cancer occurring in 10 to 20% of people with HIV.95 The second most common cancer is lymphoma which is the cause of death of nearly 16% of people with AIDS and is the initial sign of AIDS in
3 to 4%.95 Both these cancers are associated with human herpesvirus 8.95 Cervical cancer occurs more frequently in those with AIDS due to its association with human papillomavirus (HPV).95
Additionally, people with AIDS frequently have systemic symptoms such as prolonged fevers, sweats (particularly at night), swollen lymph nodes, chills, weakness, and weight loss.96 Diarrhoea is another common symptom present in about 90% of people with
AIDS.97 They can also be affected by diverse psychiatric and neurological symptoms independent of opportunistic infections and cancers.98
2.9 DIAGNOSIS OF HIV
HIV/AIDS is diagnosed via laboratory testing and then staged based on the presence of certain signs or symptoms.96
HIV testing
Most people infected with HIV develop specific antibodies (i.e. seroconvert) within three to twelve weeks of the initial infection.91 Diagnosis of primary HIV before seroconversion is done by measuring HIV-RNA or p24 antigen.91 Positive results
49 obtained by antibody or Polymerase Chain Reaction (PCR) testing are confirmed either by a different antibody or by PCR.89
Antibody tests in children younger than 18 months are typically inaccurate due to the continued presence of maternal antibodies.98 Thus HIV infection can only be diagnosed by PCR testing for HIV RNA or DNA, or via testing for the p24 antigen.89 Much of the world lacks access to reliable PCR testing and many places simply wait until either symptoms develop or the child is old enough for accurate antibody testing.98 In sub-
Saharan Africa as of 2007–2009 between 30 and 70% of the population was aware of their HIV status.99 In 2009, between 3.6 and 42% of men and women in Sub-Saharan countries were tested which represented a significant increase compared to previous years.99
HCT Services in Nigeria
HCT is an important entry point for most forms of HIV and AIDS prevention and control interventions including PMTCT, treatment and care. It also constitutes a good platform for linkage between sexual and reproductive health services and HIV/AIDS related programs.14
The percentage of persons that received an HIV test in the past 12 months is usually used as an indicator of the proportion of people who currently know their HIV status.5 Overall, the uptake of HCT is still low among the Nigerian population even though the proportion of people who had tested and received their results had increased from 2003 to 2014.5,14
According to a 2012 national survey, 23.5% of male and 29.2% of female reported ever tested for HIV.5 Out of this group, only 63% of female and 68% of males that tested for
50
HIV received their results and know their status. 36% of respondents’ aged 15 to 19 years and 42.6% of those aged 20 -24 years reported having an HIV test in the last 12 months.5
This shows that a lot more needs to be done to increase uptake of counselling and testing in order to achieve the access target for this objective.
Also in 2014, the number of HCT sites increased by 14.7% from 7075 in 2013 to 8114 in
2014.14 In spite of this increase, the proportion of the general population who has accessed HCT still remains low.14 Challenges faced by the HCT program in Nigeria include: Shortage of HIV test kits; weak supply chain and logistics management; wrong public perception that HCT is only useful for the diagnosis and management of HIV positive clients, and low HIV risk perception and the stigma associated with HIV infection.14 As at 2014, there are a total of ninety-five (95) HCT centres in Ogun State comprising of primary, secondary and tertiary health facilities.16
2.10 CLASSIFICATIONS OF HIV INFECTION
Two main clinical staging systems are used to classify HIV and HIV-related disease for surveillance purposes: the WHO disease staging system for HIV infection and disease,89 and the CDC classification system for HIV infection.100 The CDC's classification system is more frequently adopted in developed countries. Since the WHO's staging system does not require laboratory tests, it is suited to the resource-restricted conditions encountered in developing countries, where it can also be used to help guide clinical management.
Despite their differences, the two systems allow comparison for statistical purposes.89
The World Health Organization first proposed a definition for AIDS in 1986.89 Since then, the WHO classification has been updated and expanded several times, with the most
51 recent version being published in 2007.89 The WHO system uses the following categories:
Primary HIV infection: May be either asymptomatic or associated with acute
retroviral syndrome.89
Stage I: HIV infection is asymptomatic with a CD4+ T cell count (also known as
CD4 count) greater than 500 per microlitre (µl or cubic mm) of blood.89 May
include generalized lymph node enlargement.89
Stage II: Mild symptoms which may include minor mucocutaneous
manifestations and recurrent upper respiratory tract infections. A CD4 count of
less than 500/µl.89
Stage III: Advanced symptoms which may include unexplained chronic diarrhoea
for longer than a month, severe bacterial infections including tuberculosis of the
lung, and a CD4 count of less than 350/µl.89
Stage IV or AIDS: severe symptoms which include toxoplasmosis of the brain,
candidiasis of the oesophagus, trachea, bronchi or lungs and Kaposi's sarcoma. A
CD4 count of less than 200/µl.89
2.11 PREVENTION OF HIV/AIDS
A) PRIMARY PREVENTION
52
Health education about encouraging sexual abstinence, adopting positive behavioural change especially as pertaining to HIV risky behaviours e.g. unprotected sexual intercourse, sharing of sharp objects etc. (as well as improving HIV self risk-perception) are still central to most community-wide HIV prevention efforts.5
Specific Protection a) Sexual contact: Consistent condom use reduces the risk of HIV transmission by approximately 80% over the long term.101 When condoms are used consistently by a couple in which one person is infected, the rate of HIV infection is less than 1% per year.101 There is some evidence to suggest that female condoms may provide an equivalent level of protection.102
Circumcision in Sub-Saharan Africa "reduces the acquisition of HIV by heterosexual men by between 38% and 66% over 24 months".103 Based on these studies, the World
Health Organization (WHO) and Joint United Nations Programme on HIV and AIDS
(UNAIDS) both recommended male circumcision as a method of preventing female-to- male HIV transmission in 2007.103 Whether it protects against male-to-female transmission is disputed104 and whether it is of benefit in developed countries and among men who have sex with men is undetermined.104 Some experts fear that a lower perception of vulnerability among circumcised men may cause more sexual risk-taking behaviour, thus negating its preventive effects.105
Programs encouraging sexual abstinence do not appear to affect subsequent HIV risk.106
Evidence for a benefit from peer education is equally poor.106 Comprehensive sexual education provided at school may decrease high risk behaviour.106 A substantial minority
53 of young people continues to engage in high-risk practices despite knowing about
HIV/AIDS, underestimating their own risk of becoming infected with HIV.106 b) Pre-exposure Prophylaxis
Treating people with HIV whose CD4 count ≥ 350cells/µL with antiretrovirals protects
96% of their partners from infection.108 This is about a 10 to 20 fold reduction in transmission risk.109 Pre-exposure prophylaxis (PrEP) with a daily dose of the medications tenofovir, with or without emtricitabine, is effective in a number of groups including men who have sex with men, couples where one is HIV positive, and young heterosexuals in Africa.109 It may also be effective in intravenous drug users with a study finding a decrease in risk of 0.7 to 0.4 per 100 person years.110
Universal precautions within the health care environment are believed to be effective in decreasing the risk of HIV.111 Intravenous drug use is an important risk factor and harm reduction strategies such as needle-exchange programmes and opioid substitution therapy appear effective in decreasing this risk.112 c) Post-exposure Prophylaxis
A course of antiretrovirals administered within 48 to 72 hours after exposure to HIV- positive blood or genital secretions is referred to as post-exposure prophylaxis (PEP).113
The use of the single agent zidovudine reduces the risk of a HIV infection five-fold following a needle-stick injury.113 As of 2013, the prevention regimen recommended in the United States consists of three medications—tenofovir, emtricitabine and raltegravir—as this may reduce the risk further.113 PEP treatment is recommended after a sexual assault when the perpetrator is known to be HIV positive, but is controversial
54 when their HIV status is unknown.114 The duration of treatment is usually four weeks114 and is frequently associated with adverse effects—where zidovudine is used, about 70% of cases result in adverse effects such as nausea (24%), fatigue (22%), emotional distress
(13%) and headaches (9%).25 d) Safe Blood transfusion
Since the early 1980s, tremendous progress has been made in understanding, as well as decreasing, the risk of human immunodeficiency virus (HIV) transmission from blood transfusion.115 The major interventions that are used to minimize this risk include questioning of donors concerning HIV risk behaviours and laboratory testing of each donated unit of blood for antibodies to HIV-1 and HIV-2 and for HIV-1 RNA by pooling of 6 to 16 specimens (minipool nucleic acid testing, or MP-NAT).115
In United States, rate of HIV seropositivity in the blood donor population has been shown to be approximately 0.5 per 10,000 donations, a value much lower than the rate of 3.5 per
10,000 donations shortly after the introduction of routine HIV antibody screening.116
When analysed in first time blood donors, the rate is 1 per 10,000 to 20,000 donors and has remained stable.116 Because of careful donor selection criteria, it has been calculated that HIV seroprevalence in blood donors is less than 2 per cent of that expected in the adult American population.116 However, HIV transmission may still occur for if donations were made during the window period of infection (defined as the interval of time shortly after HIV infection, when the donor is infectious but has not yet developed positive HIV laboratory tests) and if the donated blood is infected with variant strains of
HIV that may escape detection by current screening assays.115
55
Various studies in Nigeria in the last decade indicates that the incidence of blood transfusion related HIV infection in Nigeria range from 1.2 – 1.8%.117,118 To control transfusion related HIV infection, the National Blood Transfusion Service (NBTS) was established in 2005, and a National Blood Policy was developed in 2006.118 Seventeen
(17) blood transfusion centres have been set up with support from the private sector, the
United States Presidential Emergency Plan for AIDS Relief (PEPFAR), the Safe Blood for Africa (SFA) and the Centre for Disease Control (CDC).117 The goals were: to actively change attitudes to encourage voluntary non-paid donations; to develop and use questionnaires to identify individuals and populations at risk for HIV and to increase self- awareness of the risk for HIV; to introduce mechanisms for self-deferral and to screen blood with antigen testing in addition to the ELISA to detect new HIV infections contracted within 16 days prior to testing.117 An ELISA alone only detects HIV contracted 90 days prior to donation. Despite the regulations introduced by the NBTS, the incidence of HIV infected blood in blood banks is still high.117 This is partly due to the fact that the guidelines outlined by NBTS have not been widely implemented and there are an insufficient number of established safe transfusion centres to meet the country’s need for safe blood. According to the Nigeria National Blood Transfusion Service
(NBTS), more than 80% of blood collected and transfused in Nigerian hospitals is not properly screened as the ELISA is still the only test used to screen donated blood for
HIV. 117; 118 e) Prevention of Mother-to-child Transmission (PMTCT)
Programs to prevent the vertical transmission of HIV (from mothers to children) can reduce rates of transmission by 92–99%.35 This primarily involves the use of a
56 combination of antiviral medications during pregnancy and after birth in the infant and potentially includes bottle feeding rather than breastfeeding.35 If replacement feeding is acceptable, feasible, affordable, sustainable, and safe, mothers should avoid breastfeeding their infants; however exclusive breastfeeding is recommended during the first months of life if this is not the case.119 If exclusive breastfeeding is carried out, the provision of extended antiretroviral prophylaxis to the infant decreases the risk of transmission.119
f) Vaccination
As yet there is no effective vaccine for HIV or AIDS.120 A single trial of the vaccine RV
144 published in 2009 found a partial reduction in the risk of transmission of roughly
30%, stimulating some hope in the research community of developing a truly effective vaccine.120
B) SECONDARY PREVENTION
This encompasses early diagnosis and treatment of HIV/AIDS.14 HIV diagnosis has been discussed in section 2.9 above and details of the various treatment modalities are discussed in section 2.12 below. Also included in this category is prevention of opportunistic infections (OIs) in HIV positive individuals occasioned by their immunocompromised state (details also in section 2.12 below).
C) TERTIARY PREVENTION: entails management of AIDS and other complications of HIV infection (details in section 2.12 below).
2.12 MANAGEMENT OF HIV/AIDS
57
There is currently no cure or effective HIV vaccine. Treatment consists of high active antiretroviral therapy (HAART) which slows progression of the disease121 and as of 2010 more than 6.6 million people were taking them in low and middle income countries.121
Treatment also includes preventive and active treatment of opportunistic infections.
Antiviral therapy
Current HAART options are combinations consisting of at least three medications belonging to at least two types, or classes, of antiretroviral agents.122 Initially treatment is typically a non-nucleoside reverse transcriptase inhibitor (NNRTI) plus two nucleoside analogue reverse transcriptase inhibitors (NRTIs).122 Typical NRTIs include: zidovudine
(AZT) or tenofovir (TDF) and lamivudine (3TC) or emtricitabine (FTC).122
Combinations of agents which include a protease inhibitors (PI) are used if the above regimen loses effectiveness.122
When to start antiretroviral therapy is subject to debate.123; 124 The World Health
Organization recommends antiretrovirals in all adolescents, adults and pregnant women with a CD4 count less than 500/µl with this being especially important in those with counts less than 350/µl or those with symptoms regardless of CD4 count.122 This is supported by the fact that beginning treatment at this level reduces the risk of death.124
The United States in addition recommends them for all HIV-infected people regardless of
CD4 count or symptoms; however it makes this recommendation with less confidence for those with higher counts.125 While the WHO also recommends treatment in those who are co-infected with tuberculosis and those with chronic active hepatitis B.122 Once treatment is begun it is recommended that it is continued without breaks (i.e. total adherence).123
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Many people are diagnosed only after treatment ideally should have begun.123 The desired outcome of treatment is a long term plasma HIV-RNA count below
50 copies/mL.123 Levels to determine if treatment is effective are initially recommended after four weeks and once levels fall below 50 copies/mL checks every three to six months are typically adequate.123 Inadequate control is deemed to be greater than
400 copies/mL.123 Based on these criteria treatment is effective in more than 95% of people during the first year.123
Benefits of treatment include a decreased risk of progression to AIDS and a decreased risk of death.126 In the developing world treatment also improves physical and mental health.127 With treatment there is a 70% reduced risk of acquiring tuberculosis.122
Additional benefits include a decreased risk of transmission of the disease to sexual partners and a decrease in mother-to-child transmission.122 The effectiveness of treatment depends to a large part on compliance.123 Reasons for non-adherence include poor access to medical care,128 inadequate social supports, mental illness and drug abuse.128 The complexity of treatment regimens (due to pill numbers and dosing frequency) and adverse effects may reduce adherence.129 Even though cost is an important issue with some medications,130 47% of those who needed them were taking them in low and middle income countries as of 2010130 and the rate of adherence is similar in low-income and high-income countries.130
Specific adverse events are related to the antiretroviral agent taken.131 Some relatively common adverse events include: lipodystrophy syndrome, dyslipidemia, and diabetes mellitus, especially with protease inhibitors.131 Other common symptoms include diarrhea,131 and an increased risk of cardiovascular disease.132 Newer recommended
59 treatments are associated with fewer adverse effects.123 Certain medications may be associated with birth defects and therefore may be unsuitable for women hoping to have children.123
Treatment recommendations for children are slightly different from those for adults. In the developing world, as of 2010, 23% of children who were in need of treatment had access.133 Both the World Health Organization and the United States recommend treatment for all children less than twelve months of age.133 The United States recommends in those between one year and five years of age treatment in those with HIV
RNA counts of greater than 100,000 copies/mL, and in those more than five years treatments when CD4 counts are less than 500/µl.133
Opportunistic infections
Measures to prevent opportunistic infections are effective in many people with
HIV/AIDS. In addition to improving current disease, treatment with antiretrovirals reduces the risk of developing additional opportunistic infections.131 Vaccination against hepatitis A and B is advised for all people at risk of HIV before they become infected; however it may also be given after infection.134 Trimethoprim/sulfamethoxazole prophylaxis between four and six weeks of age and ceasing breastfeeding in infants born to HIV positive mothers is recommended in resource limited settings.133 It is also recommended to prevent PCP when a person's CD4 count is below 200 cells/uL and in those who have or have previously had PCP.135 People with substantial immunosuppression are also advised to receive prophylactic therapy for toxoplasmosis
60 and Cryptococcus meningitis.136 Appropriate preventive measures have reduced the rate of these infections by 50% between 1992 and 1997.136
Alternative medicine
In the US, approximately 60% of people with HIV use various forms of complementary or alternative medicine,137 even though the effectiveness of most of these therapies has not been established.137 With respect to dietary advice and AIDS some evidence has shown a benefit from micronutrient supplements.138 Evidence for supplementation with selenium is mixed with some tentative evidence of benefit.138 There is some evidence that vitamin A supplementation in children reduces mortality and improves growth.138 In
Africa in nutritionally compromised pregnant and lactating women a multivitamin supplementation has improved outcomes for both mothers and children.138 Dietary intake of micronutrients at RDA levels by HIV-infected adults is recommended by the World
Health Organization.139 The WHO further states that several studies indicate that supplementation of vitamin A, zinc, and iron can produce adverse effects in HIV positive adults.139 There is not enough evidence to support the use of herbal medicines.139
HIV/AIDS has become a chronic rather than an acutely fatal disease in many areas of the world.123 Prognosis varies between people, and both the CD4 count and viral load are useful for predicted outcomes.91 Without treatment, average survival time after infection with HIV is estimated to be 9 to 11 years, depending on the HIV subtype.123 After the diagnosis of AIDS, if treatment is not available, survival ranges between 6 and
19 months.140 HAART and appropriate prevention of opportunistic infections reduces the
61 death rate by 80%, and raises the life expectancy for a newly diagnosed young adult to
20–50 years.140 This is between two thirds and nearly that of the general population.90
The primary causes of death from HIV/AIDS are opportunistic infections and cancer, both of which are frequently the result of the progressive failure of the immune system.141
Risk of cancer appears to increase once the CD4 count is below 500/μL.90
Tuberculosis co-infection is one of the leading causes of sickness and death in those with HIV/AIDS being present in a third of all HIV infected people and causing 25% of
HIV related deaths.142 HIV is also one of the most important risk factors for tuberculosis.143
The risk of developing tuberculosis (TB) is estimated to be between 12-20 times greater in people living with HIV than among those without HIV infection.143 In 2011 there were
8.7 million new cases of TB, of which 1.1 million were among people living with HIV.143
WHO recommends that all HIV-infected TB patients should be commenced on ART irrespective of their CD4 count.143 This has the potential to reduce mortality. ART should be given within 8 weeks of initiation of anti-tuberculosis treatment, however, in TB patients with a CD4 count of less than 50cells/mm3, ART should be started within 2 weeks after the onset of anti-tuberculosis treatment.143 In HIV patients with TB meningitis however immediate ART is associated with more severe adverse events, and should be delayed until the onset of anti-tuberculosis treatment. 143
62
TB-associated immune reconstitution inflammatory syndrome (IRIS) is common in patients with TB started on ART but is usually self-limiting. Patients who develop IRIS should continue their anti-tuberculosis and ART treatments. 143
The World Health Organisation (WHO) has also recommended the adoption of the Three
I’s Strategy in managing TB/HIV co-infection. 143,144 This involves: Intensified Case
Finding (ICF), Isoniazid Preventive Therapy (IPT) and Infection Control for tuberculosis
(IC). 143,144 In Intensive Case Finding (ICF) it is recommends that all people living with
HIV should be screened with a clinical algorithm at each clinical encounter. Those who do not report any one of: current cough, fever, weight loss or night sweats are unlikely to have active TB and should be offered IPT. 143,144 As regards Isoniazid Preventive Therapy
(IPT), it is recommended that people living with HIV who are unlikely to have active TB should receive at least 6 months of IPT as part of a comprehensive package of HIV care.143,144 For Infection Control for TB (IC), it is recommended that TB infection control practices should be in place in all congregate settings, and in health facilities providing
HIV care. TB infection control practices include personal, administrative, and environmental controls as well as health worker surveillance. Informing communities and the general public about these practices will also to help to reduce the spread of TB and
MDR TB to people living with HIV. 143,144
Hepatitis C is another very common co-infection where each disease increases the progression of the other.145 The two most common cancers associated with HIV/AIDS are Kaposi's sarcoma and AIDS-related non-Hodgkin's lymphoma.95
63
2.13 IMPACT OF HIV/AIDS a)Economic Impact: HIV/AIDS affects the economics of both individuals and countries.146 The gross domestic product of the most affected countries has decreased due to the lack of human capital.146 Without proper nutrition, health care and medicine, large numbers of people die from AIDS-related complications. They will not only be unable to work, but will also require significant medical care. It is estimated that as of 2007 there were 12 million AIDS orphans.146 Many are cared for by elderly grandparents.146
By affecting mainly young adults, AIDS reduces the taxable population, in turn reducing the resources available for public expenditures such as education and health services not related to AIDS resulting in increasing pressure for the state's finances and slower growth of the economy. This causes a slower growth of the tax base, an effect that is reinforced if there are growing expenditures on treating the sick, training (to replace sick workers), sick pay and caring for AIDS orphans. This is especially true if the sharp increase in adult mortality shifts the responsibility and blame from the family to the government in caring for these orphans.147
At the household level, AIDS causes both loss of income and increased spending on healthcare.146 b) Social and Psychological Impact: People living with HIV are stigmatized leading to severe social consequences related to their rights, health care services, freedom, self- identity and social interactions. It also severely hampers the treatment and diagnosis of
HIV contributing to further spread of the disease.13 Infected people are blamed for
64 causing the condition through their risky behaviour and such attitudes disrupt an individual’s social interactions and thereby lead to a feeling of isolation.14
Women in sub-Saharan Africa are infected more often and earlier in their lives than men.13 Young women aged 15–24 are between two and six times as likely to be HIV- positive than men of a similar age.13 This evens out in older age groups, but it highlights the vulnerability of young women and girls and unequal power relations in many societies.13 When women are diagnosed with HIV/AIDS, the psychosocial implications, rather than the physiological impact, become the focus.148 Though research indicates that method of transmission affects the level of stigma, this was not true in women.148 Those infected by their husbands or blood transfusions suffered as much stigma as those who contracted the virus from a sexual encounter with an unknown individual.148 Though women are more likely to disclose their HIV/AIDS status to employers than men, they are still hesitant to tell and often do not, unless it is necessary to adjust work demands to accommodate their health status.149
Children are affected by HIV/AIDS through mother to child transmission of HIV or through the loss of one or both parents from AIDS.14 The 2008 National Situation
Assessment and Analysis (SAA) on orphans and vulnerable children (OVC) showed that
HIV/AIDS has been a major cause of death of parents (especially in households where both parents have died).14 Also, loss of parents may lead to social and economic vulnerability. c) Health Impact: HIV/AIDS is known to have caused resurgence in some diseases like
Tuberculosis globally but perhaps less well known is the fact that HIV infection impairs antimalarial immunity in areas where malaria is endemic, HIV infection increases the risk
65 that an individual over five years of age will become infected with malaria and experience malaria-related diseases. 150 In five southern African countries, the WHO estimates that high HIV prevalence in rural areas increased malaria incidence by 28% and more than doubled the malaria death toll.150 d) Environmental Impact: At first glance, Millennium Development Goal 7— ensuring environmental sustainability has little to do with HIV and AIDS. Yet even here, the epidemic is having an impact. For example, a study of four fishing communities in
Uganda found that not only were fishing families hit hard by illness, but fish stocks were being depleted as unskilled youth who were replacing sick fishermen did not know or ignored the traditions that have protected these communities’ livelihoods for generations.151
Research in some African countries a decade ago revealed that HIV and AIDS was having impact on the Miombo woodlands, a vast ecoregion stretching through some of the African countries with the highest prevalence of HIV, including Angola, Malawi,
Mozambique, United Republic of Tanzania, Zambia and Zimbabwe.152 Carried out in six communities in Malawi and Mozambique, the research found that the forest was an important source of medicinal plants used by people to deal with HIV-related symptoms
(most often for diarrhoea, mouth and throat sores, rashes and fevers) and of food and fuel for HIV- and AIDS-affected families. Families that had suffered the death of one of their members (and thereby less able to afford fuel sources such as propane) were five times more likely than those unaffected to have increased their collection of firewood, denuding areas close to their settlements.152 A number of other threats were also
66 emerging. For example, medicinal plant species were threatened by destructive harvesting methods and commercial harvesting of these plants by people outside the community.152
2.14 RELIGION AND HIV/AIDS
Religion has always been seen as an effective tool for change. It is one of the popular institutions that have greatly influenced the life of many nations of the world, and also impacted on the political, social, physical, moral, spiritual and economic affairs of the modern world.153
The topic of religion and AIDS has become highly controversial in the past twenty years, primarily because some religious authorities have publicly declared their opposition to the use of condoms.153 The religious approach to prevent the spread of AIDS according to a report by American health expert Matthew Hanley titled The Catholic Church and the
Global AIDS Crisis argues that cultural changes are needed including a re-emphasis on fidelity within marriage and sexual abstinence outside of it.153
HIV/AIDS poses new challenges to religions all over the world, including Nigeria. As
HIV/AIDS-related deaths increases, the pandemic is challenging the world's mainstream religions as much as any event in modern history, setting at odds their core mission of assuaging human suffering and perfecting human morality.154 The religious leaders and those associated with faith-based organisations have the responsibility of speaking out truthfully and taking the necessary action to curb the spread of HIV and alleviate the suffering caused by HIV/AIDS.154 As trusted and respected members of the society, religious leaders are listened to; their actions set an example.155 Their strengths and
67 credibility, and their closeness to the communities afford them the chance to make a real difference in halting the spread of HIV/AIDS.155 Therefore, any messages on HIV/AIDS imparted by religious leaders are important in changing the attitudes and the behavioural patterns of their followers about the epidemic.
Since 2000, faith-based organisations (FBOs) have come to the fore in terms of the fight against HIV/AIDS. Since then, whilst some of the religious organisations have been an integral part of the control efforts against HIV/AIDS, many are yet to fully appreciate the complicated nature of this pandemic.156 Even whilst religion appears to show sympathy for people living with HIV/AIDS (PLWHAs), it is however discouraging to note that it has refused to fully accept the reality of preventing the spread of the virus through openness, advocacy and awareness.156 In this regard, the role of religion is limiting and greatly undermines the effectiveness of combating the pandemic by stakeholders.155
There are however some religious organisations in Nigeria which are making positive contributions to the HIV/AIDS control efforts amongst their members and in the communities where they are located. For example, the Redeemed Christian Church of
God (RCCG) organises regular health education on HIV/AIDS to their members as well as care for people affected by HIV/AIDS including orphans and vulnerable children.156
The main religious groups in Nigeria (i.e. Christians and Muslims) are also in the fore- front of the campaign against homosexuality which has now been passed into law by the
Federal Government and is believed to serve as a means to reduce the HIV transmission in the country.156 Also, the religious organisations of both faiths have institutionalised the practice of conducting compulsory HIV screening and counselling for all intending
68 couples and the results made known to the authorities of these faith-based organisations before such marriages could be sanctioned;156 whilst the obvious intention of this approach is to protect unsuspecting individuals from entering into a union with an HIV positive partner (who had not disclosed his/her HIV status), some other civil rights organisations have argued against this practice as it bothers on ethics of the medical profession that allows the individual to grant consent before any medical test is conducted on him/her and confidentiality maintained as regards the results of such tests.157
The traditional institutions also play an important role in the handling of HIV/AIDS stigmatisation as the traditional rulers being the chief custodians of the traditions/cultural practices and beliefs of their people can be influential agents of change.158 For instance, traditional rulers publicly going for HCT services to know their status or publicly associating with people known to be living with HIV/AIDS in their communities would be reinforcing positive attitudes to the community members as relates with HIV/AIDS.158
In Nigeria, some traditional rulers have been involved in the fight against HIV/AIDS stigmatisation in their communities with appreciable immediate impact but there still remains widespread HIV/AIDS stigma and discrimination in Nigeria.158
2.15 ROLE OF GOVERNMENT AND NON-GOVERNMENTAL
ORGANISATIONS IN ADDRESSING HIV/AIDS STIGMA
There have been several policy documents developed by various arms of the Nigerian government to address the issue of universal access to HIV/AIDS care as well as tackling
69 stigma. These enacted laws and policies were designed to guide the multi-sectoral response to HIV/AIDS.14 They include:
The National Policy on HIV/AIDS which was developed in 2009 by the National
Agency for the Control of AIDS.14 The policy provides regulations and guiding principles on topics ranging from prevention of new infections and behaviour change, treatment, care and support for infected and affected persons, institutional architecture and resourcing, advocacy, legal issues and human rights, monitoring and evaluation, research and knowledge management, and policy implementation by the various stakeholders in the national response.14 The national policy was developed in agreement with key national and international frameworks relevant to the HIV/AIDS response in
Nigeria, this includes:
i. The 1999 Constitution of the Federal Republic of Nigeria, which affirms the national
philosophy of social justice, and guarantees the fundamental right of every citizen to life
and freedom from discrimination.14
ii. Commitments to and ratification of numerous international conventions including
Universal Declaration of Human Rights (1948), the Convention on Economic,
Social and Cultural Rights (1976), the Convention on the Elimination of All
Forms of Discrimination Against Women (1979), Convention on the Rights of the
Child (1989), and the African Charter on Human and People’s Rights (2003).14
Hence, the government (especially at the federal level) has strived to provide the needed legal framework to protect HIV positive individuals (as well as their close relations) from stigma as Anti-stigma and Discrimination bill has passed by both Senate and House of
Representatives, and have been signed into law by the President.14 Advocacies are on-
70 going by the civil society groups as well as several non-governmental organisations to ensure the bill is passed and signed to law in all the States in Nigeria,14 these NGOs include Civil Society Network for HIV and AIDS in Nigeria (CiSHAN) , Network of
People Living with HIV/AIDS in Nigeria (NEPWHAN), and Nigerian Youths Network against HIV/AIDS (NYNetHA). The implementation and enforcement of these laws are however still weak in Nigeria.14
CHAPTER THREE
MATERIALS AND METHODS
3.1 Study Area
Ogun State constituted the study setting in which two Local Governments (Ado-Odo/Ota
& Ifo) were randomly selected with one serving as the intervention and the other as the
71 control. The State came into existence on 3rd February 1976 following its carving out from the old Western region of Nigeria. It is located in the South-western part of Nigeria at coordinates: 7°00′N 3°35′E;159 bounded by Lagos State to the South, Oyo and Osun
States to the North, Ondo State to the East and the Republic of Benin to the West.
Abeokuta is the capital and largest city in the State.
It has a land area of 16,980.55 km2 and a total population of 4,847,492 (with 2,409,966 males and 2,437,526 females) as at 2014 projection from the figure from the 2006 national population census 3,751,140 comprising of 1,864,907 males and 1,886,233 females.160 There are three (3) senatorial divisions/zones in the State i.e. Ogun East,
Ogun Central and Ogun West with twenty (20) Local Governments Areas (LGAs) spread across these zones (details in Appendix 4).
The State is primarily agrarian in nature but is also characterised by presence of several industries ranging from pharmaceutical, agro-allied, food and beverages as well as textiles.
The State is populated mainly by the Yoruba ethnic group with several sub-groups mainly the Egba, Yewa, Awori, Egun, Ijebu, Remo, Ikale and Ilaje, Anago, Ketu and
Ohori. There are also other non-Yoruba ethic groups that settled in the State owing largely to its proximity to Lagos (the economic capital of Nigeria) and the presence of several industries. The inhabitants are majorly farmers, civil servants, factory workers and self-employed businesses (e.g. traders, commercial transporters including motorcycle riders).
72
There are a total of 516 primary health care facilities and 21 secondary health facilities in the State. There are three (3) tertiary health facilities in Ogun State: Olabisi Onabanjo
University Teaching Hospital, Sagamu; Federal Medical Centre, Abeokuta and National
Neuropsychiatric Hospital, Aro (Abeokuta). HIV Counselling and Testing (HCT) services are rendered in most of these health facilities as well as other reproductive health services. Ogun State presently has a total of ninety-five (95) HCT centres.16 There is however no youth friendly health facility available in the State.16
Ado-Odo/Ota Local Government Area (LGA) has rural and urban settlements and is located in the Western part of Ogun State, South-western Nigeria at 6.68333oN
3.68333oE; bounded by Lagos State to the South, Ifo LGA (Ogun State) to the North and
East, and Yewa-South LGA (Ogun State) to the West.
It has a land area of 878km2 and a total population (for 2015) of 705,269 (as projected from 2006 census).160 It has sixteen (16) political wards (details in Appendix 5). The
Local Government is primarily agrarian in nature but is also characterised by presence of several industries ranging from pharmaceutical, agro-allied, food and beverages as well as textiles. It is populated mainly by the Awori people (a subset of the Yorubas and the original inhabitants of the area) however, other ethnic groups like Egba settlers, Eguns and Yewas (Egbados) also live there; there are also other non-Yoruba ethic groups that settled in the LGA owing largely to its proximity to Lagos (the economic capital of
Nigeria) and the presence of several industries. The inhabitants are majorly farmers, civil servants, factory workers and self-employed businesses (e.g. traders, commercial transporters including motorcycle riders etc.).
73
There are thirty-three (33) primary health care facilities in the LGA whose locations are spread throughout all the 16 Wards of the Local Government, fourteen (14) of these render HIV Counselling and Testing (HCT) and other reproductive health services. There is also a secondary health facility – The State Hospital, Ota.
Ifo Local Government Area is located in the Ogun Central senatorial division of the State at 6°49′00″N 3°12′00″E. It has an area of 521 km² and a population (for 2015) of 702,953
(as projected from the 2006 census).160 The Local Government is predominantly populated by all the sections of Egbas (i.e. Egba-Alake, Egba -Owu, Egba Oke-Ona and
Egba-Gbagura) and as well as some other sub-ethnic groups. The people in Ifo Local
Government area are predominantly traders, artisans and civil servants, but there are also farmers especially in the largely rural wards. The Local Government is made up of a mix of mostly quasi-urban as well as urban and some rural communities.
It is bounded by Yewa-South Local Government in the West, Ewekoro Local
Government in the North, in the East by Obafemi-Owode Local Government and in the
South by Ado-Odo\Ota in Ogun State and Kosofe, Ikeja and Ifako-Ijaiye Local
Governments in Lagos State.
It has eleven (11) political wards (details in Appendix 5).
There are twenty-nine (29) primary health care facilities in the LGA whose locations are spread throughout all the 11 Wards of the Local Government eight (8) of which render
HIV Counselling and Testing (HCT) and other reproductive health services. There is also a secondary health facility – General Hospital, Ifo.
3.2 Study Population
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Adolescents (10 – 19 years) of both sexes resident in the selected Local Governments
(i.e. Ado-Odo/Ota and Ifo LGAs).
3.3 Study design
The study was a quasi-experimental community-based study to determine the effect of health education on HIV/AIDS risk behaviours and stigmatisation attitudes among adolescents in the selected Local Governments in the State.
Two Local Governments (Ado-Odo/Ota & Ifo), randomly selected from two of the senatorial zones in the State formed the experimental and control groups respectively.
The choice of selecting the experimental and control groups from two different senatorial zones was to prevent cross interference during and after the intervention periods. From each LGA, subjects were selected from a cluster of two adjoining wards determined by a random process (see details in section 3.5).
The study was carried out in three (3) phases – Pre-intervention, Intervention and Post-
Intervention phases. Phase one (pre- intervention) involved cross-sectional comparative descriptive study, while phase two involved comprehensive health education intervention in the experimental/intervention group only. Phase three (post-intervention) involved comparative study between the experimental and control group immediate post- intervention as well as four (4) months post-intervention; there was also Focus Group
Discussion held in all the wards during this phase. Details of the training programme are in section 3.3.2.
75
Assessments were done before, immediately post- and four (4) months post-intervention.
Comparison between the groups was tested using Chi square tests. Level of significance for all tests was 5%.
3.3.1 Pre-Intervention Phase
This was conducted between February 2014 and January 2015.
These included the following (more details in Appendix 6):
1. Selection of the two Local Government Areas to be used for the study (one to
serve as the experimental (Ado-Odo/Ota LGA) and the other (Ifo LGA) was the
control). Refer section 3.5 for details.
2. Obtaining official permission to proceed with the study from the selected Local
Government Areas [LGAs] authorities.
3. Advocacy to the town-planning officials of the LGAs.
4. Selection of the two political Wards in each LGA to be used for the study i.e.
Olose & Coker/Ilepa wards (Ifo LGA) and Iju & Atan wards (Ado-Odo/Ota
LGA). Refer section 3.5 for details.
5. Constituting research team: the lead investigator was assisted by trained assistants
which included a coordinator of a local community-based organisation (CBO) –
Positive Outreach Foundation involved in HIV/AIDS youth programmes; a
trained peer educator; a secondary school teacher trained in family life and HIV
education (FLHE); two (2) volunteer persons living positively with HIV (PLPs); a
76
health worker in each of the selected Local Government Areas involved with
HIV/AIDS programme.
6. House enumeration in the selected political wards for the study (was conducted in
conjunction with town-planning officials of the LGA) as part of the process of
selection of participants for the study. These were done between 2nd and 4th weeks
in December 2014. The choice of town planning officials was informed by the
fact that they possess latest information on house structures in the Local
Governments more so that these selected LGAs had several new sites springing
up regularly due to high population influx mainly due to their proximity to Lagos
State. House enumeration was done using the House-House ‘sweep’ approach
with the aid of catchment area maps of the selected wards in the Local
Governments.
7. Informed consent of the parents/guardians of the adolescents to allow them fully
participate at all stages of the study were obtained.
8. Informed consent of the participants themselves were obtained (which
emphasised their voluntary participation and permission to withdraw further
participation from the study at any time if they so desired).
9. There was pre-testing of 20 questionnaires before the main study was conducted
using some adolescents resident in Ipokia LGA which was different from the two
Local Governments already selected for the main study. Amendments were made
to the research instrument to minimise ambiguity and improve clarity. This was
also to ensure validity and reliability of the research instrument.
77
10. There was a baseline survey to determine the HIV risk behaviours of the
adolescents in the two groups (i.e. control and intervention) as well as their
perception of risk of contracting the virus and their level of stigma towards
persons living with HIV; this represented the pre-training assessment for the
intervention group and the initial assessment for the control group.
3.3.2 Intervention Activities
The intervention consisted of a structured educational programme based on a course content adapted from the Peer Education Plus Programme for HIV intervention at the community level by the Society for Family Health (SFH) and Actionaid (supported by
DFID and USAID) and approved by the National Agency for the control of HIV/AIDS
(NACA)161-163 as well as the information obtained from the gaps in knowledge identified from the distributed questionnaires. These formed the basis of the training which only involved the experimental/intervention group.
The training was held at Iju Community Hall which was a suitable venue within the experimental LGA (i.e. Ado-Odo/Ota) which accommodated the number of participants expected; It was a two (2)-day training conducted on Sat. 3rd and Sun. 4th Jan. 2015; and the first day held between 3 – 6:30pm whilst the second day was between 4 – 6:30pm.
This was so as not to infringe on the schooling hours of the selected adolescents still undergoing school education as at the time of study. The time was communicated to all the selected adolescents beforehand.
Training sessions were for two days and were in four (4) modular units which were: (1) knowledge about HIV/AIDS and other STIs; (2) Personal Risk Perception; (3) HIV
Status, Stigma and Discrimination and (4) Care and Support and Rights of People Living
78 with HIV/AIDS (PLWHAs). The first two modules i.e. (1) and (2) above constituted the training for Day 1; while the latter two modules i.e. (3) and (4) above constituted the training for the second day.
In each module, the training methods adopted were health talks, role plays and drama as well as individual and group exercises. The personnel involved in the training included trained peer educators, Family Life and HIV Education (FLHE) trained teacher, some medical personnel working in the Local Government as well as two (2) People Living
Positively (PLPs) with HIV within the LGA (especially for modules 3 and 4 above).
Various relevant IEC materials on HIV/AIDS were deployed in reinforcing the key messages of the training. The baseline survey for the control group (in Ifo LGA) was held on Sat. 10th Jan. 2015 at llepa community hall at 3 – 5pm.
3.3.3 Post-Intervention Phase
These were conducted in two phases: immediate post-intervention and four (4)
months post-intervention.
The post-intervention evaluation was carried out using same questionnaire that
had been used during the pre-intervention evaluation to determine immediate gain
(immediate post-intervention) and the residual gain (four months post-
intervention) in HIV/AIDS-related Knowledge Attitude and Practice (KAP) after
the initial assessment in the intervention and control groups respectively.
Evaluation of the effects of the training was done using calculated scores for the
various variables during analysis.
79
There was Focus Group Discussions (FGD) conducted in all the political wards
used for the study (refer section 3.6 for details).
3.4 Sample size determination
The minimum sample size (n) was determined by the statistical formula for comparing proportions between two groups thus:
풏 = 푫(풁휶 + 풁 )ퟐ x {푷 (1 - 푷 ) + 푷 (1 - 푷 )} / (푷 − 푷 )2 164 ⁄ퟐ 휷 ퟏ ퟏ ퟐ ퟐ ퟏ ퟐ
Where,
풁휶 = Critical value of the standard normal deviate corresponding to level of ⁄ퟐ significance (훼) of 5% = 1.96.
풁휷 = Critical value of the standard normal deviate corresponding to type II error (훽) of
10% (Power = 90%) = 1.28.
D = Design effect for the sampling design used = 1.5
푷ퟏ = Proportion of adolescents (15-19 years) with perception of “No risk at all” regarding contracting HIV (NARHS Plus 2007)4 in the control group = 63.8% or 0.638.
P1 – P2 = difference in risk perception between the experimental and control groups to be detected = 20%
푷ퟐ = Proportion of adolescents (15-19 years) with perception of “No risk at all” regarding contracting HIV in the experimental group = 63.8 – 20% = 43.8% or 0.438.
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Hence, n = 1.5 (1.96 + 1.28)2 x {0.638(1 – 0.638) + 0.438(1 – 0.438)} / (0.638 – 0.438)2. n = 1.5 (3.24)2 x {0.638(0.362) + 0.438(0.582)} / (0.2)2. n = 1.5 x 10.4976 x {0.230956 + 0.243276} / 0.04. n = 1.5 x 10.4976 x 0.474232 / 0.04. n = 7.46744676/0.04 n = 154.29 ≡ 155. Therefore, calculated minimum sample size is 155.
However, to cater for attrition rate of 10%, the minimum sample size is 155/1-10% = 172 for each group (i.e. intervention and control); Further adjustment for 10% non-response gives a minimum of 172/0.9 = 192. However in this study 250 participants were recruited in each group during subject selection, but of these, only 215 participants were present at the start of the study in each group (i.e. Intervention and Control). At 4 months post-intervention, there were further reductions in the number of available participants in both study groups as only 183 were present in the Intervention group and 192 for the
Control group.
3.5 Subject Selection and Sampling Methods
A multistage random sampling technique was used to select the required samples for this study. Ogun State has three senatorial divisions/zones within which twenty (20) LGAs are located:
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Stage I (Senatorial zone selection): The first step was to choose two of the three senatorial zones in the State (i.e. Ogun West, Ogun East and Ogun Central) from which the LGAs to be used in the study were selected. This was by simple random sampling technique by balloting using same size of papers (on which names of the senatorial zones were written) and thoroughly mixed and then picking it at random; hence Ogun West and
Ogun Central senatorial zones were selected.
Stage II (LGA selection): From each of the two (2) selected senatorial zones, one LGA was picked by simple random sampling technique by balloting (names of the LGAs within each senatorial zone written on each paper) and thoroughly mixed and then picking it at random. Hence two (2) Local Governments, Ado-Odo/Ota (from Ogun West zone) and Ifo LGA (from Ogun Central zone), were selected for the study - one was the intervention group while the other the control group; the choice of which of the two (2) selected LGAs for the study became the experimental (intervention) or control group was made by tossing a coin. Hence Ado-Odo/Ota Local Government was selected to be the intervention (experimental) group whilst Ifo LGA the control.
Stage III (Ward selection):
From the list of political wards in each of the selected LGAs, two (2) wards with contiguous borders were selected by simple random sampling technique thus: the first ward was selected from the whole list of political wards in the LGA by balloting using same size of papers (with names of each ward written on each paper) and thoroughly mixed and then picking it at random; then from the adjoining wards to the first selected ward, one ward was selected by balloting also. Hence for the experimental LGA (Ado-
Odo/Ota), of the sixteen (16) wards, Iju ward was first picked; this ward has Atan and
82
Ota 2 wards as contiguous wards to it, from which Atan ward was selected by toss of a coin. Hence Iju and Atan wards together formed a single cluster from which subjects were selected for the experimental group. A similar procedure was deployed in the control LGA (Ifo) in which of the eleven (11) wards, Olose ward was first selected by balloting using same size of papers (with names of each ward written on each paper) and thoroughly mixed and then picking it at random; this ward has three (3) other contiguous wards namely Ibogun, Ikorita/Okenla and Coker/Ilepa wards from which one
(Coker/Ilepa ward) was selected by balloting using same size of papers (with names of each ward written on each paper) and thoroughly mixed and then picking it at random and these two wards i.e. Olose and Coker/Ilepa together formed a single cluster from which the selection of subjects for the control group was conducted.
Stage IV (House selection):
At the level of the selected Wards, house enumeration was carried out by the research team and some officials from the town-planning unit of the Local Governments.
From the combined total number of houses counted in the experimental and control
Wards clusters (i.e. the two (2) wards selected in each LGA), a systematic random sampling technique (using a sample interval) was deployed to choose 250 houses in each of the experimental and control wards respectively. This sample interval was determined by dividing the total number of houses enumerated in both the experimental (4,016) and the control (2,857) wards by the sample size in the experimental and control wards respectively i.e. 250 {hence 4,016/250 and 2,857/250 for the experimental and control wards respectively}. Hence the sample interval was 17 and 12 for the experimental and control wards respectively. The first house visited was determined by balloting, such that
83 in the experimental wards, a number was selected from any of the numbers from 1 to the last two digits in the total number of enumerated houses (4,016) i.e. “1 - 16”, hence the house corresponding to the selected number in the enumeration list became the first house visited; similar approach was done for the control wards.
Stage V (selection of individual adolescent participant):
Only one adolescent (age 10-19yrs) was studied per house and this was randomly selected by a simple random sampling technique carried out by balloting to choose an adolescent from a house where there were more than one adolescent even in selected houses with multiple households. Where there was only one adolescent in a house, he or she automatically qualified to participate in the study. When there was no adolescent in a selected house, then the next house to it was considered but subsequent house selection was made without prejudice to predetermined sampling interval. There were some non- consenting houses recorded in both experimental and control wards (19 and 17 respectively, hence a total of 269 and 267 houses visited respectively).
There was a line listing of all the adolescents selected for the study in each LGA (this included their names, residential addresses and where possible their phone numbers or those of their parents/guardians). This served as a register used as a quality assurance tool to ensure that only those selected were allowed to participate in the study. It was also used in accessing the participants’ contact details for the purpose of sending follow-up reminders before the scheduled dates of the training/surveys.
3.5.1 Inclusion Criteria
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Only adolescents whose parents/guardians were permanent residents and who had been residing with them (parents/guardian) in the area for at least 6 months prior to the time of study were included in the study. Consent was obtained to participate in the study from both the parents/guardian of the adolescents as well as the adolescents themselves.
3.6 Research Instrument and Data collection
A semi-structured interviewer-administered questionnaire (adapted from the
National HIV/AIDS and Reproductive Health Survey (NARHS Plus) 2007)4 was
used for data collection (Appendix 1). This was pre-tested before the main study
was conducted using 20 adolescents resident in Ipokia Local Government, Ogun
State. Amendments were made to some aspects of the instrument that were found
ambiguous or lacked clarity.
The sections of the questionnaire included: Section A consisting of socio-
demographic characteristics such as age, gender, educational background/class of
study, religion, family type; Section B which consists of questions on knowledge
of the adolescents about modes of transmission and prevention of HIV; Section C
which consists of sexual behaviour as well as their perception of risk of
contracting the virus and Section D which consists of questions to assess their
level of stigma and discrimination towards persons living with HIV.
There were Focus Group Discussions (FGDs) conducted in all the wards used for
the study (i.e. Coker/Ilepa, Olose, Iju and Atan). One Focus Group Discussion
85 was conducted in each ward (i.e. two (2) in each LGA, hence four (4) in all) and each FGD session consisted of eight (8) participants (four males and four females), a moderator/facilitator and a clerk. The participants were selected by volunteering from the wards where they resided thus: formal requests were made through the local Community Development Associations (CDAs) of each ward for adolescent volunteers (four males and four females) all of whom must not have been already involved with the main study (i.e. neither in experimental nor control groups). Consent was obtained from both parents/guardians as well as the participants themselves before proceeding with the FGD sessions. The duration of each FGD session was about 55mins and all the sessions were held between 3rd and 4th weeks of Jan. 2015.
The FGD sessions were held at the major primary health centre in each ward at a time of the day that did not coincide with major clinic sessions at the health facility. The sitting arrangement was roundtable format and all the participants were encouraged to speak freely on the various issues of interest in the study in line with the FGD Guide (Appendix 3); to this end, before commencing each
FGD session, all participants were instructed to adopt pseudo-names (e.g. aliases or initials like “A.K.”) so they wouldn’t feel apprehensive about having their real names being mentioned in the course of the FGD sessions which may impact on the quality of their contributions. The participants were encouraged to speak in any of three languages which were understood by all – English, Yoruba as well as
Pidgin English. Light refreshments were served to all the participants. The sessions were recorded by the clerk (who took notes) and there was also voice
86
recorder deployed in each FGD session to enable adequate capture of all
issues/comments raised by the participants; these recordings were transcribed
following each FGD session. Data analysis was done manually as described
above.
3.7 Data management and analysis
The questionnaires were checked for proper completion upon collection from participants. The data were entered into SPSS statistical software version 19. The data were cleaned for errors and data edited.
Composite variables (aggregate scores) for knowledge and stigmatising attitudes were computed from items on the questionnaire. For knowledge about HIV, responses from 29 items were combined. These items included knowledge and misconceptions about HIV transmission, HIV prevention, and treatment for HIV positive individuals. A correct response was given a score of 1 and an incorrect one scored 0. Thus the ‘yes’ responses for the questions on correct modes of transmission and prevention were scored 1 while this was reversed for the misconceptions. The total obtainable knowledge score was 29.
Concerning stigma and discrimination, stigmatizing attitudes got a score of 1 while accepting attitudes were scored 0. There were 16 items related to attitudes to family members, non-family members, classmates and teacher with HIV, thus the total obtainable stigma score was 16.
Risky sexual behaviour was derived by combining three variables: inconsistent condom use (defined as not using condoms everytime in the sexual acts 12 months before
87 interview), not using condom in last sex act, and having multiple sexual partners. Any respondent that satisfied any of the three criteria was classified as practising risky sexual behaviour. The analyses of the association between risky sexual behaviour and variables were based on those that were sexually active 12 months before the survey.
Data were summarized using means and standard deviation for normally distributed quantitative data and median and range for skewed data. Qualitative data was summarized using frequencies and proportions. Baseline comparisons in the distributions of categorical socio-demographic variables and HIV knowledge, testing and stigma were tested using the Chi square test.
The effect of the intervention was tested on sexual behaviour, stigma and HIV knowledge. Three approaches were used to test the effect of the intervention on the key indicators. First, change in the proportions with response to individual items was compared at baseline and immediate post intervention for the intervention group using the McNemar’s chi square test. Also change in these percentages was tested between baseline and 4 months post intervention separately for the intervention and control groups using the McNemar’s Chi square test.
Secondly the mean scores (knowledge and stigma scores) were compared between baseline and immediate post intervention for the intervention group and between baseline and 4 months post intervention for the two groups using the Paired t test.
The third approach involved calculating change in scores by subtracting the knowledge and stigma scores at baseline and 4 months post intervention. The change in scores so generated was then compared between the intervention and control groups using the
88 independent samples t test. The z test was used to compare the difference in the differences in proportions of categorical indicators between baseline and post intervention between the intervention and control groups.
In order to determine the association between stigma and socio-demographic characteristics, mean stigma scores were compared across levels of socio-demographic characteristics. For variables with two categories, independent samples t test was used to compare the groups while One-way ANOVA was used to compare variables with more than two categories. Multiple linear regression of stigma scores was also done on selected variables. The association between risky sexual behaviour in the 12 months before the study and socio-demographic characteristics was tested using Chi square tests. Level of significance for all tests was 5%.
The Focus Group Discussion (FGD) sessions were recorded by a clerk (who took notes) as well as with the aid of a voice recorder device and transcribed manually. All comments/opinions of participants regarding all the various issues discussed were noted such that all the varied comments were reported even if such comment(s) were made by only one of the entire number of participants from all the FGD groups; this was to ensure that all opinions were captured. All similar comments were grouped together and reported based on the relative number of participants that made them, hence were reported as being said e.g. ‘unanimous or all’, ‘majority’, ‘some’ or ‘few’. Any reported comment(s) made by the participants in their own words were written in italics.
3.8 Ethical Considerations
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Approval for the research proposal was obtained from the Federal Medical Centre
(FMC), Abeokuta Ethical Committee (Appendix 8). Informed consent was obtained from the management of each of the selected Local Government Areas for the study i.e. Ado-
Odo/Ota LGA and Ifo LGA (Appendix 9 and 10 respectively) and the community leaders at the selected wards within these LGAs.
Oral and written consent were obtained from the selected adolescents and their parents/guardians before their involvement in the study i.e. administering the questionnaires as well as the Focus Group Discussion (FGD) sessions. The full cooperation of the participants was solicited and they were also assured of their freedom to opt out at any stage of the project. The participants/respondents were assured of full confidentiality throughout the course of the study and this assurance was also indicated on the questionnaire (non-inclusion of self-identifying characteristics) which were also kept safe and confidential. The register used for line listing of all the selected participants for the study was kept solely in the custody of the lead investigator throughout the study and at no time was any other person granted access to it so as to protect the identity and personal contact details of the participants (also of the parents/guardians).
In the Focus Group Discussion (FGD) sessions, all the participants were asked to use pseudo names (i.e. nick names) so as to protect their identities as well as to encourage them speak freely during the sessions. Only the lead investigator had access to the true identity of each of the participants; also, only the lead investigator had access to the audio files of the recordings from the FGD sessions (and these recordings were personally transcribed by him) and the notes taken by the clerk were collected from her immediately
90 after completion of each session and no other person was allowed access to it again save the lead investigator.
3.9 Limitations
Recall bias: Some of the questions asked were sensitive especially about sexual behaviour and there is a chance that some of the responses could have been untruthful.
CHAPTER FOUR
RESULTS
RESULTS OF QUANTITATIVE STUDY
Section 4.1: Socio-demographic characteristics
Table 1 shows the distribution of socio-demographic characteristics between the intervention and control groups. The socio-demographic characteristics shows that 31.2% were males, 52.6% were adolescents aged 10-14 years and 47.4% were aged 15-19 years, while 67.3% were Christians. The two groups were similar concerning gender (X2 =
2.31, p = 0.128), age (X2 = 2.69, p = 0.101), parents’ marital status (X2 = 0.12, p = 0.729), family type (X2 = 5.57, p = 0.062), mother’s children (X2 = 2.39, p = 0.303), father’s
91 children (X2 = 1.50, p=0.473), father’s education (X2 = 2.88, p = 0.237), mother’s education (X2 = 4.75, p = 0.093) and religion (X2 = 1.16, p = 0.282).
Table 1: Comparison of socio-demographic characteristics of adolescents
Variable Intervention Control Chi square P value (n=215) (n=215) Gender Male 67(31.2) 82(38.1) 2.31 0.128 Female 148(68.8) 133(61.9) Total 215(100) 215(100) Age (years) 10-14 113(52.6) 96(42.4) 2.69 0.101 15-19 102(47.4) 119(55.3) Total 215(100) 215(100) Parents’ marital status Currently married 175(81.8) 173(80.5) 0.12 0.729 Others 39(18.2) 42(19.5) Total 214(100) 215(100) Family type Monogamous 161(75.2) 143(66.8) 5.57 0.062 Polygamous 48(22.4) 58(27.1) Widowed parent 5(2.3) 13(6.1) Total 214(100) 214(100) Mother’s children 1-3 70(32.6) 68(31.8) 2.39 0.303 4-5 119(55.3) 109(50.9)
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6+ 26(12.1) 37(17.3) Total 215(100) 214(100) Father’s children 1-3 63(29.6) 53(25.1) 1.50 0.473 4-5 91(42.7) 90(42.7) 6+ 59(27.7) 68(32.2) Total 213(100) 211(100) Father’s education Primary and below 33(15.5) 38(17.8) 2.88 0.237 Secondary 71(33.3) 84(39.3) Tertiary 109(51.2) 92(43.0) Total 213(100) 214(100) Mother’s education Primary and below 49(22.9) 54(25.1) 4.75 0.093 Secondary 75(35.0) 92(42.8) Tertiary 90(42.1) 69(32.1) Total 214(100) 215(100) Religion Islam 70(32.7) 81(37.7) 1.16 0.282 Christianity 144(67.3) 134(62.3) Total 214(100) 215(100) *Some variables have totals less than 215 due to missing values
Section 4.2: Baseline differences in key indicators
4.2.1: Baseline difference in sexual behaviour
Table 2 shows the sexual behavior of the intervention and control groups at baseline. The groups were similar at baseline concerning the sexual behaviour variables. About a quarter (24.3%) of the intervention group compared to 20.1% of the control group had ever had sex (X2 = 1.1, p = 0.295). The proportion that ever had sex was 24.2% overall among males and 20.3% among females (p = 0.332) while it was 16.6% and 16% respectively (p = 0.865) for those that had sex 12 months before the survey (data not shown). The proportion that had sex 12 months before the survey was 15.3% in the intervention group compared to 17.2% of controls ((X2 = 0.27, p = 0.601). Over two thirds in the intervention and control groups had more than one sexual partner (X2 = 0.04,
93 p = 0.848). A lower proportion of respondents in the intervention group (24.2%) compared to the control group (35.1%) used condom in the last sex act (X2 = 0.99, p =
0.321). Consistent condom use was reported by 45.5% of the intervention group compared to 67.6% of controls (X2 = 3.51, p = 0.173).
Table 2: Comparison of intervention and control groups’ baseline sexual behaviour
Variable Intervention Control Chi P value (%) (%) square Ever had sex Yes 52(24.3) 43(20.1) 1.10 0.295 No 162(75.7) 171(79.9) Total 214(100) 214(100) Had sex in the last 12 months Yes 33(15.3) 37(17.2) 0.27 0.601 No 182(84.7) 178(82.8) Total 215(100) 215(100) Number of sexual partners last 12 months 1 10(30.3) 12(32.4) 0.04 0.848 2+ 23(69.7) 25(67.6) Total 33(100) 37(100) Condom use last sex Yes 8(24.2) 13(35.1) 0.99 0.321 No 25(75.8) 24(64.9) Total 33(100) 37(100) Frequency of condom use last 12 months Everytime 15(45.5) 25(67.6) 3.51 0.173 Sometimes 11(33.3) 7(18.9)
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Never 7(21.2) 5(13.5) Total 33(100) 37(100) Oral sex last 12 months Yes 0(0) 1(2.7) 0.91 0.341 No 33(100) 36(97.3) Total 33(100) 37(100) Anal sex in the last 12 months Yes 2(6.1) 0(0) 2.31 0.129 No 31(93.9) 37(100) Total 33(100) 37(100) *Totals are inconsistent due to missing values
4.2.2 Baseline differences in self risk perception and HIV testing
Variables that are related to HIV testing and self-risk perception are shown in Table 3.
About three quarters (75.8%) of respondents in each group knew where to get an HIV test
(X2 = 0.001, p = 0.999). The proportion that ever tested in the intervention and control groups were 4.7% and 12.1% respectively, and this difference was statistically significant
(X2 = 7.76, p = 0.005). Majority of those that never tested (90.2% in the intervention and
85.7% in the control group) indicated interest to have a test (X2 = 1.92, p =0.166).
Concerning self-perceived HIV risk, majority of respondents (over 70% in the intervention and control groups) felt they were not at risk. This perception was significantly higher among the intervention group at baseline (X2 = 14.68, p = 0.001).
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Table 3: Comparison of HIV testing related variables and risk perception between study groups
Variable Intervention Control Chi P value square Know where to get an HIV test Yes 163(75.8) 163(75.8) 0.001 0.999 No 52(24.2) 52(24.2) Total 215(100) 215(100) Would like to have an HIV test among those never tested Yes 185(90.2) 162(85.7) 1.92 0.166 No 20(9.8) 27(14.3) Total 205(100) 189(100) Ever tested for HIV Yes 10(4.7) 26(12.1) 7.76 0.005 No 205(95.3) 189(87.9) Total 215(100) 215(100) Rating of chances of being infected with HIV* High 8(3.8) 14(6.5) 14.68 0.001 Low 21(10.0) 48(22.3) No risk at all 182(86.3) 153(71.2) Total 211(100) 215(100) *Totals are inconsistent due to missing values
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4.2.3 Baseline differences in stigmatizing attitudes
Responses to items related to stigmatizing attitudes are shown in Table 4. Over two thirds of respondents indicated willingness to care for family member with HIV though not significantly different between the intervention and control groups (X2 = 2.18, p = 0.140)
Concerning keeping the status of HIV positive family member secret, about 80% of respondents in the intervention group and 68.9% of controls expressed such desire (X2 =
7.01, p <0.008). Over half of respondents at baseline will encourage family member with
HIV to openly disclose status. Less than half will stop being friends with an HIV positive close friend (X2 = 15.69, p <0.001), while less than a quarter of respondents in the two groups expressed willingness to buy food from food seller with HIV (X2 = 9.19, p =
0.002). Over three quarters expressed willingness to help a support group of HIV positive people (X2 = 0.47, p = 0.493) or to remind an HIV positive friend to take drugs (X2 =
0.04, p = 0.848).
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Table 4a: Comparison of stigma and discrimination between intervention and controls at baseline
Variable Intervention Control Chi P value square Desirable attitudes Willing to care for family member with HIV Yes 182(86.7) 196(91.2) 2.18 0.140 No 28(13.3) 19(8.8) Total 210(100) 215(100) Will encourage family member to openly acknowledge HIV status Yes 137(65.9) 123(58.0) 2.74 0.098 No 71(34.1) 89(42.0) Total 208(100) 212(100) Willing to share meals with PLWHA Yes 108(51.2) 61(28.6) 22.48 <0.001 No 103(48.8) 152(71.4) Total 211(100) 213(100) Willing to sit beside PLWHA Yes 135(64.6) 93(43.5) 19.01 <0.001 No 74(35.4) 121(56.5) Total 209(100) 214(100) Willing to buy food from food seller with HIV Yes 46(21.9) 22(10.8) 9.19 0.002 No 164(78.1) 181(89.2) Total 210(100) 203(100) Agree that HIV positive female teacher be allowed
98 to teach Yes 150(69.8) 104(48.4) 20.35 <0.001 No 65(30.2) 111(51.6) Total 215(100) 215(100) Willing to sit with HIV positive classmate Yes 144(67.3) 102(47.4) 17.27 <0.001 No 70(32.7) 113(52.6) Total 214(100) 215(100) Willing to share writing materials with HIV positive classmate Yes 138(65.1) 91(42.9) 20.97 <0.001 No 74(34.9) 121(57.1) Total 212(100) 212(100) *Totals are inconsistent due to missing values
Table 4b: Comparison of stigma and discrimination between intervention and controls at baseline (contd)
Variable Intervention Control Chi P value square Desirable attitudes Willing to play with HIV positive classmate Yes 167(78.8) 99(46.0) 48.68 <0.001 No 45(21.2) 116(54.0) Total 212(100) 215(100) Willing to share meals with HIV positive classmate Yes 112(53.1) 55(25.6) No 99(46.9) 160(74.4) 33.79 <0.001 Total 211(100) 215(100) Willing to share toilet with HIV positive classmate Yes 135(64.0) 53(24.7) 66.81 <0.001 No 76(36.0) 162(75.3) Total 211(100) 215(100) Willing to help a support group of HIV positive people Yes 168(78.1) 162(75.3) 0.47 0.493 No 47(21.9) 53(24.7) Total 215(100) 215(100) Willing to participate in a support group meeting Yes 125(58.1) 86(40.0) 14.15 <0.001 No 90(41.9) 129(60.0) Total 215(100) 215(100) Willing to remind HIV positive friend/family member to take drugs
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Yes 201(93.5) 200(93.0) 0.04 0.848 No 14(6.5) 15(7.0) Total 215(100) 215(100) Undesirable attitudes Will keep status of person with HIV secret Yes 169(80.1) 146(68.9) 7.01 0.008 No 42(19.9) 66(31.1) Total 211(100) 212(100) Will stop being friends if found out close friend has HIV Yes 46(21.4) 83(39.0) 15.69 <0.001 No 169(76.6) 130(61.0) Total 215(100) 213(100) *Totals are inconsistent due to missing values
4.2.4: Baseline difference in knowledge and misconceptions
The baseline knowledge levels about HIV for the intervention and control groups are shown in Tables 5 to 7. As shown in Table 5, over 90% of respondents in both groups knew about most modes of HIV transmission except mother to child transmission, oral sex and anal sex. The intervention and control groups were significantly different in their responses to anal sex (X2 = 4.39, p = 0.036) and oral sex (X2 = 12.44, p <0.001) as modes of HIV transmission at baseline. Over half of respondents had misconceptions about mosquito bites as a mode of HIV transmission though there was no significant difference between the groups (X2 = 1.03, p = 0.311) (Table 5).
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Table 5: Comparison of intervention and control groups’ baseline knowledge and misconceptions about HIV transmission
Variable Intervention Control Chi P value (N = 214)* (N=215) square Correct modes Sexual intercourse 214(100) 208(96.7) 0.08 0.897 Blood transfusion 210(98.1) 206(95.8) 1.96 0.162 Mother to unborn child 169(79.0) 173(80.5) 0.15 0.701 Oral sex 141(65.9) 174(80.9) 12.44 <0.001 Sharing sharp objects like razor 203(94.9) 209(97.2) 1.56 0.212 Sharing needles 205(95.8) 211(98.1) 2.01 0.157 Anal sex 183(86.3) 169(78.6) 4.39 0.036
Misconceptions Sharing toilets 50(23.4) 86(40.0) 13.71 <0.001 Sharing eating utensils 53(24.9) 112(52.1) 33.44 <0.001 Mosquito bites 109(50.9) 120(55.8) 1.03 0.311 Witchcraft 26(12.1) 9(4.2) 9.08 0.003 Kissing 75(35.0) 95(44.2) 3.74 0.053 Hugging 21(9.8) 30(14.0) 1.76 0.185 *1 participant at baseline did not answer the knowledge questions
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Table 6 shows the proportions of respondents in the intervention and control groups that knew the modes of HIV prevention at baseline. Less than 80% of all respondents at baseline knew about most modes of HIV prevention except avoiding sharing sharp objects (Table 6). There were significant differences between the groups for most variables, with the knowledge higher among the intervention group for staying with one faithful partner (X2 = 3.93, p = 0.047), and reducing number of sexual partner (X2 =
24.21, p <0.001). Misconceptions about praying to God were found among almost half of respondents, 47.2% among the intervention group and 41.4% among controls (X2 = 1.46, p = 0.227). Similarly there was no significant difference in the proportion that felt that going for medical check-up was a mode of prevention (X2 = 2.24, p = 0.134).
Table 6: Comparison of knowledge of modes of HIV prevention at baseline
Variable Intervention Control Chi P value (N=215) (N=215) square Correct modes Staying with one faithful uninfected partner 158(73.5) 139(64.7) 3.93 0.047 Using condoms every time 133(62.1) 165(76.7) 10.77 0.001
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Abstaining from sex 124(57.7) 163(75.8) 15.94 <0.001 Delaying the onset of sexual intercourse 147(68.4) 167(77.7) 4.72 0.030 Avoiding sex with commercial sex workers 152(70.7) 165(77.1) 2.28 0.131 Reducing number of sexual partners 136(63.3) 85(39.5) 24.21 <0.001 Avoid sharing sharp objects 183(85.5) 182(84.7) 0.06 0.802
Misconceptions Praying to God 101(47.2) 89(41.4) 1.46 0.227 Going for medical check up 161(74.9) 147(68.4) 2.24 0.134 Using antibiotics 62(29.1) 56(26.0) 0.50 0.479 Seek protection from traditional healers 22(10.4) 26(12.1) 0.30 0.587 Do nothing 33(15.6) 68(31.6) 15.25 <0.001
Table 7 shows other items related to HIV knowledge. The intervention group had better
HIV knowledge at baseline for items related to AIDS having a cure (X2 = 31.48, p
<0.001), that an HIV positive person can live a healthy life (X2 = 18.97, p <0.001), can deliver an HIV negative child (X2 = 9.37, p = 0.009) and that a healthy looking person can be HIV positive (X2 = 94.16, p <0.001) (Table 7).
Table 7: Comparison of selected knowledge items between intervention and control groups at baseline
Variable Intervention Control Chi P value (n = 215) (n = 211) square AIDS has a cure 60(28.2) 16(7.4) 31.48 <0.001
An HIV positive person being treated can 168(78.1) 126(58.6) 18.97 <0.001 live healthy normal life
Know someone with HIV or died of 43(20.0) 43(20.4) 0.01 0.922 AIDS*
HIV positive pregnant woman can deliver an HIV negative child Yes 115(53.5) 93(43.3) 9.37 0.009
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No 50(23.3) 79(36.7) Don’t know 50(23.3) 43(20.0)
A healthy looking person can be HIV positive Yes 181(84.2) 83(39.0) 94.16 <0.001 No 29(13.5) 94(44.1) Don’t know 5(2.3) 36(16.9) *n=211 for controls (and totals are inconsistent) due to missing values
4.3: Change in key indicators between baseline and immediate post intervention
4.3.1 Change in risk perception and HIV testing in the intervention group
The responses to questions on HIV testing variables are shown in Table 8 for the intervention group. There were no improvements in the knowledge of a place to have an
HIV test (p 0.026) or intention to have an HIV test (p = 0.079) among those that never tested. However a significantly lower proportion of respondents immediate post intervention indicated that they had no risk of contracting HIV (p =0.001).
Table 8: Comparison of HIV testing related variables and risk perception at baseline and immediate post intervention for the intervention group
Intervention Variable Baseline Immediate post P value Know where to get an HIV test Yes 163(75.8) 141(65.6) 0.026 No 52(24.2) 74(34.4)
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Total 215(100) 215(100)
Would like to have an HIV test Yes 195(90.7) 182(84.7) 0.079 No 20(9.3) 33(15.3) Total 215(100) 215(100)
Rating of chances of being infected with HIV: High 7(3.5) 9(4.5) 0.001 Low 20(10.0) 49(24.4) No risk at all 174(86.6) 143(71.1) Total 201(100) 201(100) *Totals are inconsistent due to missing values
4.3.2 Change in stigmatizing attitudes
Tables 9a and 9b show the change in stigmatizing attitudes immediate post intervention compared to baseline. Generally there were significant improvements in attitude in the intervention group. In particular, there were very large improvements for willingness to share meals with PLWHA from 51.2% to 82.9% (p<0.001), willingness to buy food from food seller (21.3% to 75.4%, p < 0.001), and willingness to share meals with HIV positive classmate (from 53.4% to 80.3%, p <0.001). There were no significant improvements for keeping the status of an HIV infected person secret (p = 0.085), that female teacher with HIV be allowed to continue teaching (p =0.124) and that respondent will stop being friends with close friend with HIV (p = 0.999).
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Table 9a: Comparison of responses to stigma and discrimination items at baseline and immediate post intervention among the intervention group
Variable Baseline Immediate P value post Desirable attitudes Willing to care for family member with HIV Yes 178(87.3) 195(96.1) 0.002 No 26(12.7) 8(3.9) Total 204(100) 203(100) Will encourage family member to openly acknowledge HIV status Yes 132(66.3) 172(86.4) <0.001 No 67(33.7) 27(13.6) Total 199(100) 199(100) Willing to share meals with PLWHA Yes 108(51.2) 175(82.9) <0.001 No 103(48.8) 36(17.1) Total 211(100) 211(100) Willing to sit beside PLWHA Yes 132(64.1) 183(88.8) <0.001 No 74(35.9) 23(11.2) Total 206(100) 206(100) Willing to buy food from food seller with HIV Yes 44(21.3) 156(75.4) <0.001 No 163(78.7) 51(24.6)
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Total 207(100) 207(100) Agree that HIV positive female teacher be allowed to teach Yes 150(69.8) 165(76.7) 0.124 No 65(30.2) 50(23.3) Total 215(100) 215(100) Willing to sit with HIV positive classmate Yes 144(67.3) 186(86.9) No 70(32.7) 28(13.1) <0.001 Total 214(100) 214(100) Willing to share writing materials with HIV positive classmate Yes 134(65.0) 179(86.9) <0.001 No 72(35.0) 27(13.1) Total 206(100) 206(100) *Totals are inconsistent due to missing values
Table 9b: Comparison of responses to stigma and discrimination items at baseline and immediate post intervention among the intervention group (contd)
Variable Baseline Immediate P value post Desirable attitudes Willing to play with HIV positive classmate Yes 164(78.5) 185(88.5) No 45(21.5) 24(11.5) 0.008 Total 209(100) 209(100) Willing to share meals with HIV positive classmate Yes 111(53.4) 167(80.3) <0.001 No 97(46.6) 41(19.7) Total 208(100) 208(100) Willing to share toilet with HIV positive classmate Yes 133(63.9) 162(77.9) 0.004 No 75(36.1) 46(22.1) Total 208(100) 208(100) Willing to help a support group of HIV positive people Yes 168(78.1) 197(91.6) <0.001 No 47(21.9) 18(8.4) Total 215(100) 215(100) Willing to participate in a support group meeting Yes 125(58.1) 160(74.4) <0.001
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No 90(41.9) 55(25.6) Total 215(100) 215(100) Willing to remind HIV positive friend/family member to take drugs Yes 196(93.3) 198(94.3) 0.845 No 14(6.7) 12(5.7) Total 210(100) 210(100) Undesirable attitudes Will keep status of person with HIV secret Yes 162(79.4) 146(71.6) 0.085 No 42(20.6) 58(28.4) Total 204(100) 204(100) Will stop being friends if found out close friend has HIV Yes 46(21.4) 45(20.9) 0.999 No 169(78.6) 170(79.1) Total 215(100) 215(100) *Totals are inconsistent due to missing values 4.4: Change in indicators between baseline and post intervention
4.4.1 Change in sexual behaviour
The change in sexual behaviour for the intervention and control groups is shown in Table
10. There were significant increases in the proportion that ever had sex (p<0.001), had
sex 12 months prior to survey (p < 0.001). The proportion reporting condom use last sex
also significantly increased from 27.8% to 100% (p<0.001). There were significant
increases in the proportion that ever had sex (p<0.001), and that had sex 12 months prior
to survey (p < 0.001). The proportion reporting condom use last sex also significantly
increased from 35.1% to 67.6% (p<0.001).
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Table 10: Comparison of sexual behaviour between baseline and 4 months post intervention among the intervention and control groups
Intervention Controls
Variable Baseline 4 months P value Baseline 4 months post P value post Ever had sex: Yes 50(28.6) 80(44.0) <0001 43(22.5) 76(39.8) <0.001 No 130(71.4) 100(56.0) 148(77.5) 115(60.2) Total 180(100) 180(100) 191(100) 191(100)
Had sex in the last 12 months: Yes 33(18.0) 49(26.8) <0.001 37(19.3) 74(38.5) <0.001 No 150(82.0) 134(73.2) 155(80.7) 118(61.5) Total 183(100) 183(100) 192(100) 192(100) Number of sexual partners last 12 months: 1 3(16.7) 5(27.8) 0.876 12(32.4) 13(35.1) 0.999 2+ 15(83.3) 13(72.2) 25(67.6) 24(64.9) Total 18(100) 18(100) 37(100) 37(100) Condom use last sex: Yes 5(27.8) 18(100) <0.001 13(35.1) 25(67.6) 0.002 No 13(72.2) 0(0) 24(64.9) 12(32.4) Total 18(100) 18(100) 37(100) 37(100)
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Frequency of condom use last 12 months: Everytime 6(33.3) 12(66.7) 0.122 25(67.6) 32(86.5) 0.251 Sometimes 11(61.1) 3(16.7) 7(18.9) 2(5.4) Never 1(5.6) 3(16.7) 5(13.5) 3(8.1) Total 18(100) 18(100) 37(100) 37(100) *Totals are inconsistent due to missing values
4.4.2 Comparison of change in stigma and discrimination at 4 months between intervention and controls
In Tables 11a and 11b, the changes in stigmatizing attitudes at 4 months are shown for the intervention and control groups. Compared to controls, the intervention group had significant improvements for those items related to attitudes to family member with HIV.
For most other items there were no clear differences between the intervention and control groups.
Among the intervention group, the proportion of respondents willing to care for HIV positive relative significantly increased from 88.8% to 97.6% (p = 0.001). Also the proportion willing to share meals with PLWHA increased from 52% to 69.7% (p =
0.002). There were similar large improvements for willingness to sit beside PLWHA (p <
0.001), and to buy food from food seller with HIV (p < 0.001) among the intervention group.
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Table 11a: Comparison of responses to stigma and discrimination items at baseline and 4 months post intervention among the intervention and control groups
Intervention Control Variable Baseline 4 months P value Baseline 4 months P post post value Desirable attitudes Willing to care for family member with HIV Yes 150(88.8) 165(97.6) 0.001 174(91.6) 181(95.3) 0.210 No 19(11.2) 4(2.4) 16(8.4) 9(4.7) Total 169(100) 169(100) 190(100) 190(100) Willing to share meals with PLWHA Yes 91(52.0) 122(69.7) 0.002 52(27.8) 62(33.2) 0.343 No 84(48.0) 53(30.3) 135(72.2) 125(66.8) Total 175(100) 175(100) 187(100) 187(100) Willing to sit beside PLWHA Yes 110(65.5) 142(84.5) <0.001 82(43.2) 124(65.3) <0.001 No 58(34.5) 26(15.5) 108(56.8) 66(34.7) Total 168(100) 168(100) 190(100) 190(100) Willing to buy food from food seller with HIV Yes 39(23.1) 75(44.4) <0.001 19(10.6) 23(12.8) 0.627 No 130(76.9) 94(55.6) 161(89.4) 157(87.2) Total 169(100) 169(100) 180(100) 180(100) Agree that HIV positive female teacher be allowed to teach
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Yes 126(69.6) 147(81.2) 0.015 89(47.1) 149(78.8) <0.001 No 55(30.4) 34(18.8) 100(52.9) 40(21.2) Total 181(100) 181(100) 189(100) 189(100) Willing to sit with HIV positive classmate Yes 120(67.4) 147(82.6) 0.001 90(47.1) 122(63.9) 0.003 No 58(32.6) 31(17.4) 101(52.9) 69(36.1) Total 178(100) 178(100) 191(100) 191(100) Willing to share writing materials with HIV positive classmate Yes 117(66.1) 129(72.9) 0.188 80(42.6) 104(55.3) 0.021 No 60(33.9) 48(27.1) 108(57.4) 84(44.7) Total 177(100) 177(100) 188(100) 188(100) *Totals are inconsistent due to missing values
Table 11b: Comparison of responses to stigma and discrimination items at baseline and 4 months post intervention among the intervention and control groups
Intervention Control Variable Baseline 4 months P value Baseline 4 months P post post value Desirable attitudes Willing to play with HIV positive classmate Yes 135(78.5) 146(84.9) 0.152 85(44.5) 125(65.4) <0.001 No 37(21.5) 26(15.1) 106(55.5) 66(34.6) Total 172(100) 172(100) 191(100) 191(100) Willing to share meals with HIV positive classmate Yes 92(53.8) 122(71.3) 0.001 45(23.6) 79(41.4) 0.001 No 78(46.2) 49(28.7) 146(76.4) 112(58.6) Total 170(100) 171(100) 191(100) 191(100) Willing to share toilet with HIV positive classmate Yes 113(66.1) 124(72.5) 0.222 44(23.0) 78(40.8) 0.001 No 58(33.9) 47(27.5) 147(77.0) 113(59.2) Total 171(100) 171(100) 191(100) 191(100) Willing to help a support group of HIV positive people Yes 147(81.2) 156(86.2) 0.253 144(75.4) 168(88.0) 0.002 No 34(18.8) 25(13.8) 47(24.6) 23(12.0) Total 181(100) 181(100) 191(100) 191(100) Willing to participate in a
112 support group meeting Yes 112(61.9) 150(82.9) <0.001 72(37.9) 109(57.4) 0.001 No 69(38.1) 31(17.1) 118(62.1) 81(42.6) Total 181(100) 181(100) 190(100) 190(100) Willing to remind HIV positive friend/family member to take drugs Yes 171(94.5) 177(97.8) 0.180 178(92.7) 178(92.7) 0.999 No 10(5.5) 4(2.2) 14(7.3) 14(7.3) Total 181(100) 181(100) 192(100) 192(100) Undesirable attitudes Will stop being friends if found out close friend has HIV Yes 36(19.7) 21(11.5) 0.036 73(39.5) 26(14.1) <0.001 No 147(80.3) 162(88.5) 112(60.5) 159(85.9) Total 183(100) 183(100) 185(100) 185(100) *Totals are inconsistent due to missing values 4.5: Comparison of responses to HIV testing items and risk perception at baseline and 4 months post intervention between intervention and controls
The effect of the intervention on selected HIV testing indicators is shown in Table 12.
There were no significant improvements in knowledge of a place to test or ever testing
for HIV. In the intervention and control groups, fewer respondents indicated willingness
to have a test 4 months post intervention. In the intervention this willingness reduced
from 90.7% to 79.8% (p = 0.006) while among controls it significantly reduced from
86.5% to 77.1% (p = 0.033). However a lower proportion of respondents in the
intervention group felt they had no risk of being infected with HIV post intervention.
Among controls, the proportion with no self-perceived risk significantly increased from
70% to 89.4% (p <0.001).
Table 12: Comparison of HIV testing related variables and risk perception at baseline and 4 months post intervention for the intervention and control groups
Intervention Control 113
Variable Baseline 4 months P value Baseline 4 months P post post value Know where to get an HIV test: Yes 139(76.0) 138(75.4) 0.999 147(76.6) 142(74.0) 0.615 No 44(24.0) 45(24.6) 45(23.4) 50(26.0) Total 183(100) 183(100) 192(100) 192(100) Would like to have an HIV test: Yes 166(90.7) 146(79.8) 0.006 166(86.5) 148(77.1) 0.033 No 17(9.3) 37(20.2) 26(13.5) 44(22.9) Total 183(100) 183(100) 192(100) 192(100) Ever tested for HIV: Yes 10(4.7) 17(7.9) 0.230 26(12.1) 17(7.9) 0.200 No 173(94.5) 166(90.7) 166(86.5) 175(91.1) Total 183(100) 183(100) 192(100) 192(100) Rating of chances of being infected with HIV: High 6(3.5) 16(9.4) (<0.001) 11(6.1) 2(1.1) <0.001 Low 18(10.5) 58(33.9) 43(23.9) 17(9.4) No risk at all 147(86.0) 97(56.7) 126(70.0) 161(89.4) Total 171(100) 171(100) 180(100) 180(100)
*Totals are inconsistent due to missing values Section 4.6: Comparison of change in indicators between the intervention and control groups (difference of difference)
4.6.1 Comparison of change in risky sexual behaviour between intervention and control groups
Table 13a shows the comparison of reduction in risky sexual behaviour between the
intervention and control groups. There was a higher reduction in risky sexual behavior in
the intervention group (42.5%) compared to the control group (27.4%), however the
difference of this reduction was not statistically significant (p =0.163).
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Table 13a: Comparison of change in risky sexual behaviour between the intervention and
control groups
Intervention Control Baseline 4 months % Baseline 4 months % Z P value (%) post Reductio (%) post Reductio interventi n in risky interventi n in risky on (%) sexual on (%) sexual behaviour behaviour Risky sexual behavior
Yes 25 (75.8) 11(33.3) 42.5 24(64.9) 16(37.5) 27.4 1.34 0.163 No 8 (24.2) 22(66.7) 13(35.1) 21(62.5) Total 33 (100) 33(100) 37(100) 37(100)
Table 13b shows the difference in the study groups concerning changes in sexual
behavior variables at baseline and 4 months post intervention. The change in proportion
that had sex 12 months before the study was significantly higher among controls
compared to the intervention group (p = 0.002). Condom use last sex was much improved
in the intervention compared to control group (p = 0.003).
Table 13b: Comparison of the change sexual behaviour between baseline and 4 months post intervention between the intervention and control groups
Change: Post – Pre (%) Variable Intervention Control (%) Z P value *Totals are inconsistent due to missing values
115
(%) Ever had sex Total (191) 15.4 17.3 0.50 0.478
Had sex in the last 12 months 8.8 19.2 2.94 0.002 Total (192)
Number of sexual partners last 12 11.1 2.7 1.07 0.229 months Total (37)
Condom use last sex 72.2 32.5 3.04 0.003 Total (37)
Frequency of condom use last 12 months Everytime 33.4 18.9 1.13 0.212 Total (37)
4.6.2 Comparison of changes in stigma scores between the intervention and control groups
Table 14a shows the differences in the change in proportions with different stigma items.
There were significantly higher differences in the change in the proportion willing to share meals with PLWHA (p<0.001) and in those willing to buy food from food seller with HIV (p<0.001) among the experimental compared to control groups. However the improvement was significantly higher among controls for the proportion that agreed that an HIV positive female teacher be allowed to teach (p <
0.001).
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Table 14a: Comparison of change in proportion with responses to stigma and discrimination items at baseline and 4 months post intervention between the intervention and control groups
Variable Change in % (Post – Pre) Z P value Desirable attitudes Intervention Control (%) (%) Willing to care for family member with HIV 8.8 3.7 1.98 0.053 Total (190)
Willing to share meals with 17.7 5.4 3.70 <0.001 PLWHA Total (187)
Willing to sit beside PLWHA 19 22.1 0.73 0.246 Total (190)
Willing to buy food from food seller with HIV 21.3 2.2 5.73 <0.001 Total (180)
Agree that HIV positive female teacher be allowed to teach 11.6 31.7 4.86 <0.001
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Total (189)
Willing to sit with HIV positive classmate 15.2 16.8 0.42 0.386 Total (191)
Willing to share writing materials with HIV positive 6.8 12.7 1.92 0.058 classmate Total (188) *Totals are inconsistent due to missing values
Table 14b shows the differences in the change in proportions with more stigma items.
There were significantly higher differences in the change in the proportion for controls
compared to the intervention group for the significant variables. Significantly higher
proportions that were willing to play with HIV positive classmate (p < 0.001), willing to
share toilet with HIV positive classmate (p < 0.001), willing to help a support group of
HIV positive people (p = 0.013), and will not stop being friends if found out close friend
has HIV (p<0.001). However the intervention groups had a significantly higher
proportion willing to remind HIV positive friend/family member to take drugs compared
to controls (p = 0.019).
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Table 14b: Comparison of change in proportion with responses to other stigma and discrimination items at baseline and 4 months post intervention between the intervention and control groups
Variable Change in % (Post – Pre) Z P value
Desirable attitudes Interventio Control (%) n (%) Willing to play with HIV positive classmate Total (191) 6.4 20.9 4.16 <0.001
Willing to share meals with HIV positive classmate 17.5 17.8 0.07 0.913 Total (191)
Willing to share toilet with HIV positive classmate 6.4 17.8 3.41 <0.001 Total (191)
Willing to help a support group of HIV positive people 5 12.6 2.62 0.013 Total (191)
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Willing to participate in a support group meeting 21 19.5 0.36 0.843 Total (190)
Willing to remind HIV positive friend/family member to take 3.3 0 2.49 0.019 drugs Total (192)
Undesirable attitudes Will stop being friends if found out close friend has HIV Total (185) 8.2 25.4 4.59 <0.001 *Totals are inconsistent due to missing values
The changes in stigma scores are shown in Table 15 for the intervention and control
groups. Stigma scores significantly reduced immediate post intervention for the
experimental group (t = 9.53, p <0.001). There was also a significant reduction in stigma
scores for both the intervention (t = 4.92, p <0.001) and control groups at 4 months post
intervention (t = 4.33, p < 0.001).
Table 15: Change in stigma score over follow up period for the intervention and control groups
INTERVENTION GROUP Baseline Immediate post N Paired t P value Mean (SD) Mean (SD) test 6.1(3.7) 2.8(2.4) 173 9.53 <0.001
Baseline 4 months post Paired t P value Mean (SD) test
120
5.8(3.5) 3.7(3.2) 141 4.92 <0.001
CONTROL GROUP
Baseline 4 months post Paired t P value Mean (SD) test 8.4(3.8) 6.6(3.7) 165 4.33 <0.001
*Totals are inconsistent due to missing values
The reduction in stigma scores were computed and compared between the intervention
and control groups. There was no significant difference in the reduction in stigma scores
between the intervention and control groups (p = 0.952) (Table 16).
Table 16: Comparison of change in stigma scores at four (4) months between the experimental and controls groups
Group N* Mean Median Mann P value reduction reduction in Whitney in stigma stigma score U score (SD) (range) Intervention 141 2.2(4.8) 2(23) 11586 0.952 Control 165 1.8(5.4) 2(24)
*The totals are lower than the respective totals available post intervention due to missing data
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4.6.3 Comparison of change in responses to HIV testing and self-risk perception
post intervention between intervention and controls
The change in the proportion of HIV testing variables between baseline and 4 months
post intervention were compared between respondents in the intervention and control
groups and the results are shown in Table 17. The intervention group was significantly
better concerning HIV testing (p < 0.001) and self-perceived HIV risk compared to
controls (p < 0.001).
Table 17: Comparison of the change in proportions with HIV testing related variables and risk perception between the intervention and control groups
% change 4 months Post - Pre Variable Intervention Controls (%) Z P value (%) Know where to get an HIV test Total (192) -0.6 -2.6 1.56 0.142
Would like to have an HIV test -10.9 -9.4 0.48 0.471
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Total (192)
Ever tested for HIV 3.2 -4.2 3.82 <0.001 Total (192)
Rate self at risk of being infected with HIV 29.3 -19.4 12.74 <0.001 Total (180)
*Totals are inconsistent due to missing values
4.6.4 Comparison of change in responses to knowledge items post intervention
between intervention and controls
Table 18 shows the change in knowledge pre and post intervention. There were
significant improvements in overall HIV knowledge among the intervention group both
immediate post intervention (t = 4.8, p < 0.001) and 4 months post intervention (t = 3.6, p
<0.001). In the control group however, there was only a marginal increase in the
knowledge score at 4 months and the increase was not statistically significant (t = 1.69, p
= 0.092).
Table 18: Change in knowledge score over follow up period for the intervention and control groups
INTERVENTION GROUP
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Baseline Immediate post N Paired t P value Mean (SD) Mean (SD) test 22.3(3.1) 23.9(3.1) 178 4.8 <0.001
Baseline 4 months post Paired t P value Mean (SD) test 22.4(3.2) 23.7(2.9) 159 3.6 <0.001
CONTROL GROUP
Baseline 4 months post Paired t P value Mean (SD) test 21.9(3.3) 22.4(2.9) 185 1.69 0.092 *Totals are inconsistent due to missing values
Table 19 shows the comparison of change in knowledge scores between the intervention and control groups. The intervention group had higher but non-significant improvements in HIV knowledge compared to controls (U = 13183, p = 0.096).
Table 19: Comparison of change in knowledge scores at four (4) months between the experimental and controls groups
Group N* Mean Median Mann P value improvement improvement Whitney in knowledge in knowledge U score (SD) score (range) Intervention 159 1.3(4.1) 1(20) 13183 0.096 Control 185 0.6(4.4) 0(24) *Totals smaller than 183 and 192 respectively for intervention and control groups due to missing data
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4.7: Association between risky sexual behaviour 12 months before interview and socio-demographic characteristics
The association between risky sexual behaviour and respondents’ socio-demographic characteristics is shown in Table 20. There was a significant association between risky sexual behaviour and fathers education (p = 0.008). However, the proportion that practiced risky sexual behavior was lower among respondents whose fathers had tertiary education (88.5%) or had primary education or lower (71.4%) compared to those with secondary education (47.8%). There was no significant association between risky sexual behaviour and other characteristics.
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Table 20: Association between risky sexual behaviour and variables among those that had sex in the last 12 months
Variable Risky sexual behaviour Yes No Total Chi square P value Gender Male 21(60.0) 14(40.0) 35(100) 3.33 0.068 Female 28(80.0) 7(20.0) 35(100) Total 49(70.0) 21(30.0) 70(100) Age (years) 10-14 29(74.4) 10(25.6) 39(100) 0.80 0.372 15-19 20(64.5) 11(35.5) 31(100) Total 49(70.0) 21(30.0) 70(100) Parents’ marital status Currently married 38(66.7) 19(33.3) 57(100) 1.62 0.203 Others 11(84.6) 2(15.4) 13(100) Total 49(70.0) 21(30.0) 70(100) Family type Monogamous 35(70.0) 15(30.0) 50(100) 0.95 0.621 Polygamous 12(66.7) 6(33.3) 18(100) Widowed parent 2(1000) 0(0) 2(100) Total 49(100) 21 70(100) Mother’s children 1-3 12(70.6) 5(29.4) 17(100) 0.50 0.781 4-5 26(66.7) 13(33.3) 39(100) 6+ 10(76.9) 3(23.1) 13(100) Total 48(69.6) 21(30.4) 69(100) Father’s children
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1-3 11(73.3) 4(26.7) 15(100) 2.16 0.340 4-5 19(61.3) 12(38.7) 31(100) 6+ 19(79.2) 5(20.8) 24(100) Total 49(70.0) 21(30.0) 70(100) Father’s education Primary and below 15(71.4) 6(28.6) 21(100) 9.63 0.008 Secondary 11(47.8) 12(52.2) 23(100) Tertiary 23(88.5) 3(11.5) 26(100) Total 49(70.0) 21(30.0) 70(100) Mother’s education Primary and below 15(65.2) 8(34.8) 23(100) 2.14 0.343 Secondary 16(64.0) 9(36.0) 25(100) Tertiary 18(81.8) 4(18.2) 22(100) Total 49(70.0) 21(30.0) 70(100) Religion Islam 19(61.3) 12(38.7) 31(100) 2.01 0.156 Christianity 30(76.9) 9(23.1) 39(100) Total 49(70.0) 21(30.0) 70(100) *Totals are inconsistent due to missing values
4.8: Association between stigma and socio-demographic characteristics
(bivariate and multivariate analysis)
The differences in stigma scores across levels of categorical variables are shown in Table
21. There was only a significant difference for family type, where the mean stigma scores were highest among respondents that had widowed parents, followed by those from polygamous homes and those monogamous homes (F = 5.72, p = 0.004). Post hoc tests for pairwise comparisons found significant differences between adolescents that had widowed parents and those from and monogamous homes (p = 0.002), and between widowed parents and those from and polygamous homes (p = 0.035). Stigma scores at baseline were also correlated with knowledge scores. There was a weak negative but
127
significant correlation between knowledge and stigma (r = -0.27, p<0.001) (result not
shown in table).
Table 21: Comparison of stigma scores across categories of socio-demographic variables for all participants (intervention and controls combined) at baseline
Variable Mean stigma SD N Independent P value score samples t OR F test** Gender Male 6.74 4.17 135 1.57 0.118 Female 7.40 3.84 255 Age (years) 10-14 7.10 3.83 185 0.33 0.744 15-19 7.23 4.07 205 Parents’ marital status Currently married 7.13 4.00 312 0.52 0.605 Others 7.39 3.84 77 Family type Monogamous 6.93 4.02 274 5.72 0.004* Polygamous 7.61 3.72 94 Widowed parent 9.68 3.48 18 Mother’s children 1-3 7.39 3.89 127 0.27 0.761 4-5 7.05 4.06 204 6+ 7.16 3.87 58 Father’s children 1-3 7.01 3.92 107 0.18 0.832 4-5 7.16 4.08 161
128
6+ 7.33 3.88 118 Father’s education Secondary and below 7.49 4.10 208 1.64 0.173 Tertiary 6.79 3.92 179 Mother’s education Primary and below 7.25 3.99 100 0.07 0.934 Secondary 7.08 4.00 146 Tertiary 7.21 3.95 143
**Independent samples t test was used to compare mean stigma scores of dichotomous variables while the F test was used to compare the means of variables with more than two categories (multichotomous variables).
The variables significant at 20% on t tests and F tests (gender, family type and father’s
education) were entered into a multiple linear regression. The regression coefficients and
95% confidence intervals are shown in Table 22. Respondents from polygamous homes
or widowed parents had significantly higher mean stigma scores (p = 0.049) compared to
those from monogamous homes. Gender and father’s education were not significant.
Table 22: Multiple linear regression of stigma scores at baseline on variables
Variable Regression 95% CI for P value coefficient regression coefficient Gender Female 0.52 -0.21 to 1.27 0.161 Male
Family type
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Polygamous/Widowed parent 0.83 0.01 to 1.67 0.049 Monogamous
Father’s education Secondary and below 0.71 -1.46 to 0.04 0.065 Tertiary
RESULTS OF QUALITATIVE STUDY
Focus Group Discussion (FGD) Findings
Focus Group Discussions (FGD) were organized in each of the four (4) wards used for the study using the FGD Guide (refer Appendix 3) in which for each session, eight (8) participants comprising equal number of males and females were involved. The following themes (and sub-themes) were identified on manual analysis:
(1) Knowledge of HIV/AIDS
Majority were of the opinion that HIV was the virus that causes AIDS. Most also said it was a deadly disease that had no cure (but can be controlled or managed). However, few believed that when one was having persistent stooling, then it was likely to be
HIV/AIDS. Some even said HIV/AIDS used to be considered as highly dreaded and
130 deadly until the advent of the Ebola fever outbreak, hence many now had a change of perception about HIV/AIDS as being milder than the more dreaded and deadlier Ebola; especially as HIV/AIDS does not kill the affected person once s/he took proper care of him/herself.
(a) HIV Transmission
The most common view was that it could be transmitted through unprotected sexual contact and other sources like sharing sharp objects like razor blades, needles (e.g. for hair fixing by females); but majority also said it was not common to contract the virus through these other means due to increased awareness about benefits of sterilization of the equipment used. Many of the participants said HIV was transmitted through blood transfusion while only some of them thought it could be transmitted from an infected pregnant mother to her unborn child and through kissing. However, few participants had other views about HIV transmission which included: “HIV is transmitted through poor hygiene”, “HIV/AIDS is purely a Sexually Transmitted Infection (STI) and not transmitted through other means” and “sharing sharp objects can not lead to transmission of HIV even if they had come in contact with a person’s blood so long as the object has been left for breeze to blow on it for at least 5-10mins after which it is safe to use (as any HIV present would have been destroyed)”. A female participant was of the opinion that “AIDS killed faster than HIV”.
(b) HIV Prevention
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Most participants believed that this could be achieved by avoiding sharing sharp objects which also included items used for personalized services like manicure/pedicure, fixing hair, clippers used in barbing salon etc. and in the event that any of these items were to be used for another person, they must be adequately sterilized before use. Also, most of them believed prevention could be by regular condom use during sexual intercourse, avoiding contact with blood and secretions of other persons by wearing gloves when handling materials containing these substances as well as ensuring that any blood to be given for transfusion is thoroughly screened for the virus. However, few participants opined that it could be achieved by regular HIV counseling and testing especially by sexual partners. A female participant believed that abstinence from sex only (as HIV was transmitted only through sexual intercourse).
(2) Sexual Behaviour(s)
(a) Types of Sexual Activity
Most of them affirmed they knew of ‘Traditional’ heterosexual intercourse (aka ‘Daddy
& Mummy’ sex) as well as oral sex (genital contact of one with the mouth of another person regardless of gender of any of the individuals involved, also known as ‘Code 69’,
‘Blow-job’, ‘mouth sex’, ‘Licking plate’ – when done on females). Other types of sexual activity stated by some participants were anal sex (genital contact of one with the anus of another person (i.e. male-male or male-female), also known as ‘Code 21’), Penis-on- thigh, Penis-on-breast, Hand-job (hand on genitals) and sucking of breast. One of the male participants mentioned virtual sex (or Internet sex) in which an individual uses an
132 interactive medium to have sex with another person via the internet by self-stimulation of his/her own sensitive body parts.
(b) Relationship of Sexual Activity and HIV transmission
Most believed that ‘Traditional’ heterosexual intercourse was most likely to spread HIV than other types of sexual activity as it consisted of direct contact with vagina; whilst the safest was virtual sex since it did not involve any physical body contact with another person. There were several other varied opinions of the other types of sexual activities for instance, some believed that oral sex could spread it more than other types especially if the person applying his/her mouth on the other’s genital is HIV negative (whilst the other person is HIV positive); whilst others said oral sex could not transmit HIV (so long as there was no contact with blood) because saliva does not harbour the virus; some also said that anal sex could transmit HIV but less likely as would ‘traditional’ heterosexual sex. Yet few of the participants said that none of anal sex, breast sucking and hand-job could transmit HIV.
(c) Sexual Behaviour Patterns
(i) of sexually active friends
Majority of them said they had several friends who were already sexually active, but most of these friends did not believe in condom use as they were not really convinced about the existence of HIV. Some participants said that most of their friends did not like to use condom during sex (in spite of being aware of the existence of HIV) because they would not enjoy the sexual act with condom; rather, they practiced withdrawal method
133 whenever they were about to ejaculate so as to prevent unwanted pregnancy. A female participant said that one of her friends (a female) preferred anal sex as she believed that the ‘traditional’ heterosexual sex was only for married couples and she did not like to have it with condom. Only few of the female participants stated that none of their friends was sexually active.
(ii) of participants themselves
It was the opinion of all of them that only males wore condom. However, there were several other varied opinions shared by the participants about condom: majority of them said they did not like to use condom during sexual intercourse as it affected their enjoyment of the sexual activity (it was like ‘licking sweet with the wrapper intact’), hence they practised withdrawal method always; few said that they preferred using condom (it protected against HIV and pregnancy) and it did not reduce their enjoyment of the sexual act whenever they used it. There were also few participants who said that they knew the benefit of condom use and most times used it when having sex (except with their regular partner). The above notwithstanding, there were also several interesting views shared by yet few other participants, for instance, a female participant said that she did not like use of condom during sex, rather, she drank certain herbal mixtures
(immediately after having unprotected sex) to ‘wash out’ the semen from inside her vagina; the names of the herbal preparations included: “pepper soup”, “ogogoro”, others were – mixture of “laila” herb with 7-Up® soft drink, mixture of 7-Up® with
“Alabukun” (a local brand of antipyretic). Another female said that she did not use condom during sex, even if her partner had condom to use, she would ask him not to
134 bother; hence she liked to stick to only one sexual partner at a time and ensured that both of them went for regular HIV test to ascertain their status (a view shared by another female participant though she and her partner had not yet gone for any HIV test).
(3) Self-Perceived Risk of HIV
All the participants stated they could not be infected with HIV. Whilst majority of them further stated that they could never be infected regardless of the activities they might be engaging in, some held this view provided they were practicing safe sex or abstaining from sex. Others gave reasons which included that they had only one sexual partner with whom they went for regular HIV test every four (4) months and they also did not share sharp objects.
(a) opinions on activities that increase HIV risk
Most stated that they could only be infected if they practised unprotected sex with more than one sexual partner as well as sharing sharp objects with other persons. Few participants said they could get infected if they engaged in kissing.
(4) HIV Counseling and Testing (HCT)
(a) Importance of knowing one’s HIV status
Most felt that going for regular HCT services helped to ensure that one may properly practice safe sex with one’s partner who also must be regularly tested and to also help one seek care early in the event of one testing positive for HIV. Some were of the view
135 that if one tested HIV negative, s/he would be encouraged to avoid acts that could make him/her contact the virus while others felt that if one tested HIV positive, it would make the person more careful in activities involving other individuals that could make them prone to getting the virus e.g. sexual intercourse, sharing sharp objects etc. Few participants were of the view that a person that tested HIV positive would be better persuaded to avoid activities that could worsen his/her general health condition even as s/he seeks proper care for the condition.
(b) Personal experience(s) of HCT
Some of the participants said they had never gone for HIV testing, but most of those who had done so said they were very afraid the first time they did the test especially the period between the test and getting the result, but were very relieved to have an HIV negative result. Only one participant said she was happy to go for the test and had been doing so regularly (every three months) ever since. Few of them gave reasons for their apprehension about the test results: a female participant said she was very afraid because the hair-dresser whom she patronized for several years was said to have died of AIDS when she decided to have an HIV test; another female said her reason was that she found out that her boyfriend (with whom she had hitherto been having regular unprotected sex) also had multiple other sexual partners. Two male participants said they were so scared that they were yet to get the result of the test and they had not gone for another HCT ever since. A female participant said she was ten (10) years old when her parents first took her for the test but failed to inform her which test it was, hence she was not afraid, but the next time she would voluntarily go for the test, she was afraid.
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(5) Stigma and Discrimination in HIV/AIDS
(a) Experiences with HIV positive individual(s)
Only some of them said they knew someone with HIV. Three (3) participants knew neighbours who were positive for the virus and they were sent to the village for treatment where they later died. One female participant said she was surprised to see a female neighbour who was said to be HIV positive still looking healthy. A male participant said he knew a man at his workplace who had tested positive for HIV for some time and kept his status a secret until a day that the company ordered a mandatory HIV screening for all staff after which he was the only person asked to wait behind (this got all the other staff curious), he did not come to the company again following that incident. Another female participant mentioned the case of a neighbour’s sister who had HIV and whose husband warned the neighbour not to bring her back to his house when he found out about her status; hence she was sent back to the village where she eventually died; the participant affirmed that her knowledge of the woman’s condition did not affect how she had always related with her, but was surprised and disappointed at the manner of reaction of her husband to her condition. Another participant mentioned a woman whose husband had gone for HIV test months earlier and had discovered he was HIV positive but failed to disclose it to the wife (yet they continued having unprotected sex) whilst he secretly continued going for Anti-retroviral treatment at a health facility; soon enough, the woman started falling ill repeatedly and when she was tested, it turned out to be HIV positive.
The participant said she was outraged at the action of the man and considered it wicked of him to deliberately infect his wife with HIV. Another male participant spoke of a close
137 friend (with whom they shared same bed) and got to know through another mutual friend that he was HIV positive, but he got even closer to him and encouraged him that his positive HIV status was not the end of the world.
(b) Opinions on possible reactions to an HIV positive result
The most common response was that they would feel very sad and afraid but would immediately seek proper medical treatment for the condition; however, few had views like fainting, go for deliverance (in church) and even willingness to commit suicide.
There were few other participants (male and female) who said they would not believe the test results at first, but would wait for a month and go for a repeat test, if it was still positive, then life goes on (they however would not refrain from sexual activity within the one month waiting period). A particular male participant said he would be afraid but would immediately direct his thoughts to the last three (3) females he had engaged in sexual intercourse with to try and know who could have been the one that he might have contracted the virus from. Another male participant said he would endeavour to look at the positive side as it could be an opportunity to start an organization to support people living with HIV/AIDS (PLWHAs).
(c) Suggestions on proper attitudes towards people living with HIV/AIDS
(PLWHAs)
Most of them agreed that they should be treated with love but many of them said this should be done with some boundaries in place like no physical body contact (e.g. handshake, hugging, sitting closely etc.) and no eating from same plate though these
138 participants would not like to be so treated if it were them that were infected. Few participants said they should not be stigmatized nor discriminated upon as this may trigger actions from these HIV positive individuals that may be harmful to both themselves and others e.g. suicide, determination to infect unsuspecting members of their community. A participant said that the government should provide necessary care at no expense to people living with HIV, whilst another said these persons should be sacked from their workplace but adequately compensated.
(6) Peculiar Health Needs of Adolescents
Majority of them spoke in relation to the attitude of the health personnel at the health facilities whenever they visited to seek care. Whilst some said there should be more understanding by the health workers on the peculiarities of young people like themselves as they tend to be easily embarrassed when some sensitive issues were not handled maturely e.g. question like “when last did you have sex?”, others said they were often wrongly judged by the health personnel (as well as the adult care-givers) when they went for medical care; this was against the backdrop that as adolescents, they tend to have plenty of questions in their minds for which they would desire answers whenever they visited the health facility. A particular female participant even said whilst going for treatment for an ailment in a hospital (accompanied by her mother), the doctor asked questions about her last menstrual period and directed her to go for a pregnancy test; the test had not even been done yet when her mother had started beating her. Another female participant opined that as adolescents were very vulnerable and delicate, there should be
139 emotional and psychological support for them which should be provided specially at designated health facilities such as Youth Friendly health centres.
(b) Availability of Youth-friendly health clinics in community
All the participants were unanimous in stating that no health facility in their neighbourhood was able to meet their peculiar health needs as adolescents.
CHAPTER FIVE
DISCUSSION
The Focus Group Discussion (FGD) revealed that most of the participants had correct knowledge about HIV as the virus that causes AIDS as well as in knowing that AIDS has no cure, however, there existed several misconceptions about how the virus is transmitted and how these transmissions can be prevented. This finding is similar to that from two recent national surveys4; 5 as well as an Osun State study of secondary school adolescents.47 This evidently shows that there is need for more enlightenment
140 programmes to be organised for adolescents in our communities aimed at bridging the gaps in their knowledge of HIV and AIDS as it is with the right information that these adolescents may be better equipped to refrain from engaging in risky behaviours that would make them prone to contracting the virus.4; 5; 14
Various types of sexual activities were known to the participants and the most common of these was the ‘traditional’ heterosexual intercourse and it was this type of sexual activity that was believed by majority of them to be a means of spreading HIV because it entails contact with a female’s vagina. This was also similar to the finding from a national survey in which most of adolescents aged 15-19 years indicated sexual intercourse as a means of HIV transmission.5 The fact that many of these participants considered other types of sexual activity (like anal and oral sex) as safe as regards HIV transmission smacks of ignorance about the sexual activities that could transmit the virus, hence this could affect their choice of activities that could make them prone to contracting the virus. The above findings were corroborated by the finding that most of the participants had friends that were already sexually active who habitually practised unprotected sex with their partners and this was similar to the affirmation of most of the participants themselves that they were not in the habit of using condoms whenever they engaged in sexual activity. This finding of disconnect between good knowledge about
HIV and healthy sexual behaviour is similar to the findings from an Edo State study of secondary school adolescents.43 This is rather curious that these participants, who seemed to have knowledge of the existence of HIV and affirmed that the virus can be spread through sexual intercourse (especially heterosexual intercourse), were the same that were engaging in sexual activities without any condom use. In a national survey, it was
141 similarly found that though most of the adolescents knowledge about condom use, but less than half of them actually used condoms during last sexual act.5 Hence there seems to be a sharp disconnect between their knowledge about HIV and the avoidance of activities that could make them contract the virus, so this gap in knowledge and attitude needs to be bridged with appropriate information and constructive engagement with the adolescents. The main concern of the participants as it relates to their sexual activities was the prevention of unwanted pregnancy; hence their choice of several means of achieving this such as ingestion of various local preparations which they believed helps to wash semen out of a female’s body. In a recent national survey, most of the adolescent respondents who were sexually active and used condoms gave prevention of HIV/STIs and unwanted pregnancy as their reason for condom use.5
The above finding perhaps explains why all the participants had no self-perceived risk of ever contracting HIV as they felt they could never be infected with the virus. This is also similar to the finding from a national survey in which more than half of the adolescents believed they had no risk at all of being infected with HIV.5 This is very significant more so that for there to be a chance of a positive change of behaviour as it relates to HIV risk, the individual must believe s/he could be infected hence would be more likely to modulate his/her behaviour so as to prevent this possibility (i.e. HIV infection) from ever occurring.
As regards HIV counselling and testing (HCT), most of the participants considered it very important especially because in their view, knowing one’s HIV status would help the individual take necessary actions that would promote his/her health such as not engaging in risky activities that could lead to HIV infection (if one tested HIV negative),
142 also if one tested HIV positive one may seek proper care early and refrain from activities that may make others prone to contracting the virus from him/her. This is very encouraging and could form a basis on which further intervention programmes are organised for these adolescents that would encourage them to voluntarily go for HCT services which could also help to improve their attitudes towards HIV positive individuals as well. This is very instructive more so that some of the participants had never gone for HCT before and most of those who had done so do not go for repeat tests regularly, whilst few did not even wait to get their results the first (and only) time they did it due to fear of the outcome though similar apprehension was shared by all participants who had done HIV test before especially during their first experience. In a national survey, almost half of the adolescents who had an HIV test did not receive their result5 and this corroborates the finding from the participants in the FGD.
The responses of the participants regarding their personal experiences of knowing HIV positive individuals betrays the reality of stigma and discrimination that exist in their communities be it the workplace environment as well as in the family (nuclear or extended). This was further emphasised by the participants’ responses to a hypothetical scenario if they tested positive to HIV in which the overwhelming response was that they would feel very sad and afraid. Even when the participants spoke regarding how HIV positive individuals should be treated in society, their responses showed that they have tendencies to stigmatise HIV positive persons in spite of them displaying awareness about the ills of stigma. Hence as emphasised in a recent national survey and corroborated by latest update report on HIV/AIDS in Nigeria, there is need for more rigorous interventions to be done at the individual, family and community levels (not
143 least amongst adolescents) to address these stigmatising tendencies of members of the community against HIV positive individuals as the stigma and discrimination remain major drivers of the HIV epidemic.5; 14
The unanimous opinion of the participants regarding the capacity of existing health facilities in their communities to cater for their peculiar health needs as adolescents showed a gross inadequacy in these facilities to care for adolescents, this is similar to the findings in a national report on assessment of reproductive health issues affecting youths in Nigeria in which it was discovered that there was gross inadequacy of youth-friendly clinics throughout the country;165 hence the need to have adolescent (or youth) friendly health facilities established as well as comprehensive training and re-training of health staff on the appropriate approach to caring for adolescents.
In the quantitative part of the study, the socio-demographic characteristics of study participants showed that respondents in the intervention and control groups were mostly females from monogamous homes, predominantly Christian, with about half of both parents having attained tertiary education. The higher proportion of Christians is similar to findings from a previous school based intervention in south-western Nigeria,46 though there were more females in this study compared to previous local school based interventions.43,46,60 The proportion of Christians and those with educated parents is however higher than that reported by a study of secondary school students in Nigeria.60
The two groups were similar concerning demographic characteristics and parents’ variables, thus observed changes (in knowledge and attitudes on HIV/AIDS) in the two groups were more likely to be due to the intervention and not to differences between the groups.
144
Generally the level of knowledge about HIV transmission and prevention were good at baseline. The overall knowledge scores at baseline were between 21 and 23 in the study groups, over 70% out of a total obtainable of 29. Additionally, the proportion of respondents that knew sexual intercourse, blood transfusion, sharing sharp objects and sharing needles was higher than 90%. While this is an encouraging finding, there still exists a relatively high level of misconceptions. For example, over 20% of respondents in the intervention and control groups felt that sharing toilets, eating utensils were means of
HIV transmission. These figures are similar to those reported by a recent national survey where 22% felt sharing toilets and 18% thought sharing eating utensils could transmit
HIV. However the proportion of over 50% that indicated mosquito bites.5 This figure is similar to 50% reported by an Osun State study among secondary school adolescents47 but was much lower in two recent national surveys such as in 2012 and 2013 where figures of 21% and about 40% respectively were reported.5; 166
About a tenth of the study participants felt that HIV could be spread through witchcraft and hugging, similar to 11% and 8% reported by the 2012 national survey.5 Kissing was however reported by about 40% in this study lower than 54% reported in the Osun State study32 higher than 21% reported in the 2012 survey5 and slightly over a quarter reported by the 2013 survey.166
Misconceptions about modes of HIV transmission certainly have a role to play in accepting attitudes towards those with the disease, thus efforts at reducing misconceptions are necessary in reducing stigma. In this study the intervention educated the students and tried to correct the misconceptions.
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Less than 80% knew about oral sex and anal sex as modes of HIV transmission. Though these modes of transmission become risky when there is no protection, campaign messages need to emphasize the high HIV risk associated with these sexual behaviours.
The stigma associated with oral and anal sex especially in the traditional African society suggests that innovative approaches to discussion of oral and anal sex are needed.
Compared to the modes of HIV transmission, the knowledge about HIV prevention was lower. In fact only avoidance of sharp objects was known by over 80% of the respondents.
However the proportions of 76% and 63% at baseline among intervention and control groups respectively are similar to 75% reported by the 2012 survey5 and about 72% by the 2013 survey.166 A higher proportion of the respondents in this study reported consistent condom use during sex (64% among intervention and 76% among controls) compared to 56% by the 2012 survey5 and about 58% reported by the 2013 survey.166
Concerning other modes of HIV prevention, a higher proportion of respondents in this study correctly identified the modes compared to figures reported by the 2012 survey,5 with the largest difference found for delaying the onset of sex where over 70% of the study groups correctly identified compared to about 49% of 15-19 year olds in the 2012 survey.5 Praying to God was mentioned by almost half of respondents, an indication of the level of religiosity in Nigeria. Interventions need to continually aim at correcting these misconceptions.
Concerning other HIV related knowledge items, less than a quarter of participants felt that AIDS has a cure, a figure similar to 13% reported by the 2012 survey5 but less than
29% reported by the Osun State study.47 Similarly about 21% of the study participants
146 knew someone with HIV or that died of AIDS, close to about 18% reported by the 2012 survey.5 Over 80% of those in the intervention group and slightly over a third of controls knew a healthy looking person could be HIV positive; these were consistent with the
FGD findings in which several participants did not know that an HIV positive person could look healthy. By comparison 57% of 15-19 year olds from the 2012 survey5 and a
50% in a study of adolescents in Osun State8 knew this possibility. The fact that over half of the respondents knew that an HIV positive person could live a healthy normal life, and that just less than half knew a pregnant woman could have an HIV negative child are pleasing findings. However efforts are needed to inform more young people about the developments on HIV treatment over the years and how those that test positive can benefit. Such efforts are likely to reduce stigmatization among young people.
Concerning HIV testing related variables, three quarters of those studied knew where to get an HIV test, higher than slightly over half reported in 2012 and 2013 from the national surveys respectively.5; 166 The figure in this study is also higher than 30% found by an Ibadan-based study.167 This difference could be an indication of more awareness about HIV testing in the community since 2013. An encouraging finding is the over 85% that indicated interest in having an HIV test. This suggests that when HIV testing services are made available and affordable there is a good chance of getting more adolescents to test for HIV. However only about 6% of the intervention and 11% of controls had ever tested for HIV similar to 7% reported by an Ibadan-based study.167 Compared to Nigerian national surveys, about 13% of those aged 15-19 years in the 2012 survey had ever tested.5 The availability of free HIV testing services specifically designed to be
147 adolescent friendly has the potential to improve the proportion that ever tested for HIV especially since majority of those that never tested indicated interest in testing.
Concerning self-perceived risk of respondents, over 70% of the intervention and control groups felt they had no risk of being infected with HIV. This figure is worse than the
55% reported by the 2012 survey5. The implications of the high rate of low self-perceived
HIV risk are the tendency for respondents to engage in risky sexual (and other) behaviour and a low degree of interest in having an HIV test to know their status. The intervention in this study aimed at correcting such misconceptions.
The outcome of the intervention showed a significant improvement in HIV knowledge at
4 months post-intervention compared to baseline among the intervention group compared to the control group. In addition, the improvements in knowledge at immediate post intervention appeared to be sustained at 4 months post intervention. Previous intervention studies among adolescents have shown significant improvements in HIV knowledge.44,48,54,60,62,63
Additionally concerning self-risk perception about being infected with HIV, the proportion indicating they had no risk at all reduced significantly between baseline and immediate post intervention and was sustained at 4 months in the intervention group.
Specifically, there was a 29% increase in the proportion with self-rated HIV risk in the intervention group compared to a reduction of 19% among controls. This positive change on risk perception has the potential to reduce risky sexual behaviour and encourage higher HIV testing. There was also an increase in the proportion that ever tested for HIV of 3.2% in the intervention group compared to a reduction of 4.2% for the control group.
The intervention could be beneficial in getting adolescents to test for HIV.
148
Regarding accepting attitudes towards people living with HIV (PLHIV) vis-a-vis stigma and discrimination, the respondents in this study had fair levels of accepting attitudes, as the mean scores were 6 in the intervention and 8 among controls at baseline out of a total stigma score of 16. While there were very positive attitudes concerning caring for family member with HIV and reminding HIV positive friend to take drugs, the responses to most other items on attitude were less positive. In fact less than a quarter of respondents indicated willingness to buy food from HIV positive food seller. Generally less than two thirds would share meals with or sit beside HIV positive non-family member, share materials or writing materials with classmate. These results indicate that more campaigns are needed to correct these stigmatizing behaviours among adolescents. The 2012 survey reported 43% was willing to share meals with HIV infected person, and that compares with about 40% found in this study.5 In addition, about 38% of 15-19 year olds in the
2012 survey,5 and 44% from the 2013 national survey166 was willing to buy food from infected shopkeeper, higher figures than about 16% found in this study.
Another related finding is the high proportion (about 70%) that would keep the status of a family member with HIV secret. This proportion is even higher than the 60% and 65% respectively from the 2012 survey5 and 2013 survey.166 Keeping the HIV status of a family member secret portends negative consequences for the HIV positive individual as early access to treatment and other benefits of HIV care are missed once HIV status is kept secret. A related finding is that less than two thirds will encourage family member to openly acknowledge HIV status. Interventions such as the one in this study, especially with new and innovative methodologies are urgently needed to correct several
149 stigmatizing and discriminatory attitudes found among the adolescents in this study. It appears that the relatively high level of knowledge does not translate to accepting attitudes towards persons with HIV.
The study also revealed significant associations between stigma, family type and HIV knowledge. The lowest stigma scores were found among adolescents from monogamous homes compared to those from other homes. This finding could be an indication that those from monogamous homes are more tolerant, as they reside in homes with smaller families, with fewer siblings and perhaps better bonded with family members. Thus they may be more likely to care for family members and other people needing help. The inverse association between HIV knowledge and stigmatizing attitudes to PLWHA found in this study has been reported by previous studies among antenatal attendees in South- south region of Nigeria81 and among adults in Ghana.168 It is apparent that lower levels of misconceptions about HIV transmission and prevention would translate to more tolerant behaviour towards PLWHA. The implication of this association is that efforts at improving HIV knowledge must be intensified, as stigma levels are also likely to reduce.
The association between stigma and father’s education was not significant but lower stigma scores were found among those whose fathers had tertiary education. The educational level of the parent is likely to positively influence the child’s level of information about social and health issues generally and this could reduce their levels of stigma. Studies have also shown significantly lower levels of stigma among those with higher education.81, 168
150
Concerning gender differences in stigma, males had lower stigma scores than females, however the difference was not statistically significant. Previous studies in Nigeria have reported higher accepting attitudes among males.80, 169
The intervention instituted appeared beneficial among the intervention group especially when the responses immediate post-intervention are compared to baseline. The mean stigma score reduced from 6 at baseline to 2.8 immediate post, but rose to 3.7 at 4 months post intervention. Looking at some of the individual stigma items, the proportions willing to sit beside person with HIV, to buy food from HIV infected shopkeeper, to share writing materials, or share meals with classmate reduced between immediate post intervention and 4 months post.
This initial reduction at immediate post intervention followed by a rise in stigma levels at
4 months suggests that the effect of the intervention may not be sustained. An explanation for this finding is that some of the stigmatizing attitudes are ingrained in the minds of the adolescents and will require regular exposure to interventions to correct some of the stigmatizing attitudes. A previous systematic review has noted that the stigma reduction interventions usually work on a small scale and their impacts are short term.170
One way to ensure regular exposure to education about HIV is the inclusion of HIV
AIDS as compulsory subjects to be taken by all students for those in school, while regular community interventions should also focus on those adolescents out of school.
A surprising finding is the significant reduction in attitudes among the control group similar to the intervention group at 4 months. In fact when the reduction in stigma scores
151 at 4 months were compared between intervention and control groups, there was no significant difference between the intervention and control groups. There were some stigma items that the responses to them got worse after the intervention. For example, the proportion of respondents that would keep the HIV status of family member secret reduced slightly immediate post intervention (though not significant) but rose marginally at 4 months post intervention. In particular, there were only three items where there were significant improvements in the intervention compared to the control group: “willing to share meals” (17.7% vs 5.7%), “willing to buy food” (21.3% vs 2.2%) and “willing to remind HIV positive friend/family member to take drugs” (3.35 vs 0%). Surprisingly, for five other items: “will not stop being friends with HIV positive friend” (8.2% vs 25.4%),
“agree that HIV positive female teacher be allowed to teach” (11.6% vs 31.7%), “willing to play with HIV positive classmate” (6.4% vs 20.9%),” willing to share toilet with an infected person” (6.4% vs 17.8%), and “willing to help a support group of HIV positive people” (5% vs 12.6%), there were significant improvements in the responses from the control group compared with the intervention group at 4 months.
The reasons for significant reductions in stigma among the control group at 4 months are not clear. It is not impossible however that the participants may have been exposed to education about HIV AIDS issues through other forums.
Other interventions that found significant reductions in stigma levels include those in a
Thailand community;171 among adults living close to PLWHAs in South Africa;87 and among sex workers, men who have sex with men and young married women in India.88 A three-pronged intervention made up of monthly campaigns, funfair and Information, education and communication materials in Thailand similarly reduced community level
152 stigma.171 An intervention among primary school children in Thailand similarly found more supporting attitudes to children with HIV AIDS after education on HIV prevention.172 A Nigerian study reported that secondary school students were more tolerant of people living with HIV after a health education intervention.60 Similarly a peer education intervention in China improved accepting attitudes of high school students towards PLWHAs.62
The intervention in this study didn’t seem to markedly reduce stigma and more innovative interventions need to be tried in future studies. Some studies have highlighted the importance of community factors on accepting attitudes towards PLWHA.80, 173, 174
This suggests that interventions targeting whole communities as well as individuals such as adolescents could be more successful in reducing stigma. Such large-scale interventions need to be tried by HIV AIDS programmes and governmental organizations.
Assessment of the participants’ sexual behaviour revealed that less than a quarter (22%) of the respondents reported they ever had sex among both males and females. Compared to other studies, a study of in-school adolescents in South-west Nigeria175 found a proportion of 28.5% while a similar study in another Western Nigerian city found a proportion of 12% among adolescents.56 A higher proportion of 50% was reported by another study in Western Nigeria58 and 63% by yet another study in South-west
Nigeria.59 The 2012 national survey reported that 19.2% of males and 37.4% of females aged 15–19 years had ever had sex,5 while the 2013 Nigerian survey reported 15.5% of males and 43.8% of females had ever had sex.166 A South-West Nigeria study of in-
153 school adolescents also found 37.6% of males compared with 20.4% of females had ever had sex.175 Similarly, another study in same region of the country reported that 77.8% of males and 52.3% of females in secondary schools were sexually active.59
The wide range of proportions that ever had sex from the different studies could reflect the different methodologies used in measuring sexual behavior, age of respondents and study setting. Recent sexual activity (defined in this study as sex 12 months before interview) was reported by about 16% of study participants and is similar to 16% among
15-19 year old males in the 2012 national survey,5 though 32% of females in the survey reported recent sexual activity.5 The 2013 Nigerian survey however reported that about
11% of females and 7% of males had sex 12 months before interview.166
This study focused on three main sexual behavours risk factors: multiple sexual partner relationships, condom use last sex and consistent condom use. The study found about two thirds of respondents that had sex 12 months before interview had multiple sexual partners. This proportion is similar to that reported by an Ilesa study in Southwest
Nigeria58 and a rural community in Rivers state,179 but higher than most previous studies40, 57, 176, 180 that reported less than half of students reporting multiple sexual partners. The multiple sexual partner relationships reported here is disturbing, especially given the fact that the figures could be underestimated due to social desirability.
Condom use in the last sex act was reported by over two thirds of sexually active respondents while over half reported consistent condom use, findings which are similar to studies from Delta State,41 Benue and Ekiti States,180 in Rivers,179 and Osun States.181
Lower rates of condom use last sex were reported by other studies,40, 42, 182
154
This study found about less than 5% of all respondents had ever had oral sex and anal sex respectively. Higher figures for oral sex and anal sex of 13% and 12% were reported respectively in a study among secondary school adolescents in Osun State.40 The figures in this study are much lower than the 47.2% and 15.2% respectively reported by an
Ibadan study.176 The lower figures could be explained by the fact that the Ibadan study worked with only senior secondary school students who are relatively older than the study population in this present study. Additionally, there is the possibility of under- reporting by the adolescents, as these behaviours are not commonly discussed in the open.
Overall this study found no significant effect of the intervention on risky sexual behaviour. Specifically, there was a 42.5% reduction in risky sexual behavior in the intervention group compared to 27.4% of controls. This agrees with a study in Jos,
Nigeria65 and a South African study53 but is in contrast to previous similar studies that found significant reductions in risky sexual behaviour.46, 51, 60 Other studies in China and the United States demonstrated positive changes in behaviour intentions concerning sexual behaviour and condom use.54, 62, 177 There are a number of explanations for the failure of this study to improve condom use or significantly reduce risky sexual behaviour in the intervention group compared to controls. First, in the number of sexually active adolescents, the denominator for the analysis of condom use last sexual act was small, making the ability to detect any significant differences weaker. Secondly, the four months of post-intervention may not have been optimal to allow for behaviour change.
Lastly, sexual behaviour is a sensitive subject and the responses are subject to social desirability bias, and that could mask any possible significant changes.
155
However, concerning specific sexual behaviour variables, there was an increase of 8.8% absolute percentage units in the proportion that had sex 12 months before survey in the intervention group compared to 19.2% implying that fewer students in the intervention group had sex for the first time at 4 months follow up. Also, there was an increase of
72.2% in the proportion reporting condom use last sex in the intervention compared to
32.5% of the control group. These two latter comparisons suggest some benefit of the intervention on sexual behaviour.
Concerning factors associated with risky sexual behaviour, only father’s education was significantly associated with risky sexual behaviour as risky sexual behaviour was higher among those whose fathers had lower education. This finding is in tandem with previous studies suggesting adolescents from families with lower socioeconomic class tend to practice riskier sexual behaviour.183, 184 Several variables were not significantly associated with risky sexual behavior possibly due to the small number of sexually active respondents on which the analysis was based.
Strengths and Limitations of the study
This study is one of very few interventional studies focusing on stigmatizing attitudes towards persons with HIV people among adolescents as several other studies have examined effects of different interventions on sexual behaviour,43, 46, 51 Reproductive
Health issues45, 46, 51 and HIV AIDS knowledge.60 Additionally the effect of the intervention on self risk perception about contracting HIV was also tested, another aspect of HIV that is seldom the focus of HIV AIDS intervention.
This study was however not without its limitations. First, there were differences in the study groups concerning baseline knowledge of HIV; however the differences pre and
156 post intervention (difference of differences pre and post intervention) were mainly used to assess the effect of the interventions, and any baseline differences would be less important. Secondly, some of the questions asked were sensitive especially about sexual behaviour and there is a chance that some of the responses could be untruthful. Thirdly, there is the possibility that study participants in the control group could have got curious and found out about the questionnaire items during follow up, thus increasing the proportion with improved responses post intervention especially as regards those pertaining to stigmatizing attitudes.
Conclusion
This study has found a high prevalence of risky sexual behavior among study participants and there was no significant change in risky sexual behaviour in the intervention group when compared to controls though the proportion that had sex 12 months before interview reduced in the intervention group . There was also no significant difference in reduction of stigma between the intervention and control groups at 4 months post- intervention. However overall HIV knowledge and risk perception significantly improved in the intervention compared to the control group. Stigmatizing attitudes at baseline were significantly lower among adolescents from monogamous homes compared to those from other homes, and among those with higher HIV knowledge. Risky sexual behaviour was significantly higher among respondents whose fathers had lower education. More innovative interventions are still required to reduce stigmatizing attitudes and risky sexual behaviour amongst adolescents.
157
Recommendations
1. Urgent community-based interventions are needed to reduce the risky sexual
behaviour found in this study.
2. Greater emphasis should be given to correction of misconceptions about HIV
AIDS transmission and prevention in HIV education programmes, as reduction in
misconceptions is likely to reduce stigmatizing attitudes.
3. Specific educational interventions needed to design innovative strategies that will
reduce the proportion of adolescents that perceive themselves as having no risk of
HIV infection, as a perception of some measure of risk of contracting the virus
would more likely lead to positive modulation of behaviour.
4. Adolescent peer educator network at the community level should be strengthened
with regular (properly designed) training and re-training to equip them (peer
educators) with relevant current information on issues pertaining to
misconceptions and stigma as relates to HIV/AIDS.
5. Free HIV testing services or at highly subsidized prices need to be put in place
for young people in the communities especially given that majority of those that
never tested in this study expressed interest in having a test.
6. HIV educational materials given to adolescents should include more of (and give
greater emphasis to) materials correcting misconceptions and those promoting
accepting attitudes towards PLWHAs.
7. Stigma reduction interventions need to focus more on adolescents from
polygamous homes and those with poor HIV knowledge as this study has shown
higher stigmatizing attitudes among them.
158
8. Interventions focused on risky sexual behaviour should focus more attention on
adolescents from low socioeconomic class especially those whose fathers had low
level of education.
9. Establishment of Youth Friendly Clinics in the communities that would focus
more on meeting the peculiar health needs of adolescents especially against the
backdrop that in this study, it was a general consensus of the respondents in the
Focus Group Discussions (FGDs) that these facilities though very beneficial to
them, were non-existent in their communities.
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APPENDIX 1 (STUDY QUESTIONNAIRE) FMCA/470/HREC/07/2014
My name is Dr. Olalekan A. Oke, I am conducting a study to assess the HIV/AIDS risk behaviours and stigmatisation attitudes among adolescents in Ogun State.
The study hopes to find out valuable information concerning your knowledge about HIV/AIDS as well as your attitude towards persons who are infected with the virus that causes AIDS. Your honest responses to the following questions will assist leaders of this community and government to provide better services to help adolescents and other young people deal with this disease. Your participation is entirely voluntary and you have the right to withdraw your consent at any time during the study. Thank for your anticipated cooperation.
SECTION A: SOCIO DEMOGRAPHIC CHARACTERISTICS 1. How old were you as at last birthday? …………….. yrs.
2. Sex: (1) Male (2) Female
3. What is your Religion? (1) Islam (2) Christianity (3) Traditional (4) Others (please specify)______
4. Type of family: (1) Monogamous (2) Polygamous (3) Widowed father (4) Widowed mother (5) Others (Please specify)______5. Number of mother’s children:……………. 6. Number of father’s children:……………… 7. Marital status of parents: (1) Married (2) Separated (3) Widowed mother
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(4) Divorce (5) Others (please specify)______
8. Level of father Education: (1) None (2) Quranic (3) Primary School (4) Secondary School (5) Tertiary (6)Others (please specify)______
9. Level of Mother’s Education: (1) None (2) Quranic (3) Primary (4) Secondary (5) Tertiary (6) Others (please specify)______10. Occupation of father (please specify):…. ……………… 11. Occupation of mother (please specify):………..………..
SECTION B: KNOWLEDGE ABOUT HIV/AIDS AND PERSONAL RISK PERCEPTION
12. Have you ever heard of HIV/AIDS? 1. Yes 2. No
13. If Yes to 12) above, what is your source of information 1. YES 2. NO i. Television ii. Radio iii. Family iv. Friends v. Leaflets/Posters vi. School vii. Health Workers viii. Church/Mosque ix. Others (pls. specify)…………………………………… 14. Knowledge of route of HIV transmission:
How can a person get the Virus that causes AIDS? (kindly indicate)
a. Sexual intercourse 1. Yes 2. No
b. Blood transfusion 1. Yes 2. No
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c. Mother to unborn child 1. Yes 2. No
d. Oral sex 1. Yes 2. No
e. Sharing sharp objects like razor blade 1. Yes 2. No
f. Sharing needles 1. Yes 2. No
g. Anal sex 1. Yes 2. No
h. Others (please specify)______
15. Can HIV be transmitted by:
a. By sharing toilets 1. Yes 2. No
b. By sharing eating utensils like plates, spoons etc. 1. Yes 2. No
c. By mosquito bites 1. Yes 2. No
d. By witchcraft 1. Yes 2. No
e. By kissing 1. Yes 2. No
f. By hugging 1. Yes 2. No
16. HIV Prevention:
What can a person do to avoid getting the virus that causes AIDS? 1. YES 2. NO a. Staying with one faithful uninfected partner b. Using condoms every time c. Abstaining from sex d. Delaying the onset of sexual intercourse e. Avoiding sex with commercial sex workers f. Reducing number of sexual partners g. Avoid sharing sharp objects h. Others (please specify)______17. Can a person prevent getting HIV by: (kindly indicate)
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a. Praying to God 1. Yes 2. No
b. Going for medical check-ups 1. Yes 2. No
c. Using antibiotics 1. Yes 2. No
d. Seek protection from traditional healers 1. Yes 2. No
e. Do nothing 1. Yes 2. No
18. Does AIDS have a cure? 1. Yes 2. No
19. (a) Can a person who is HIV positive and is being treated with drugs live a healthy normal life? 1. Yes 2. No
(b) Please give reason(s) for your answer in (19a.) above ______
______
20. Do you know a person who has HIV and AIDS or who died of AIDS? 1. Yes 2. No
21. Can an HIV positive pregnant woman give birth to a child that is HIV negative? (kindly indicate) 1. Yes 2. No 3. I Don’t Know
22. Can a healthy looking person be HIV positive? 1. Yes 2. No 3. I don’t know
HIV Counselling and Testing:
23. Do you know where to get an HIV test? 1. Yes 2. No
24. If you have never been tested, would you like to do an HIV test to know your status? 1. Yes 2. No
25. For those who said ‘Yes’ to (24) above, why do you desire to have an HIV test?
To reduce fear and anxiety 1. Yes 2. No
To know my status 1. Yes 2. No
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For marriage 1. Yes 2. No
Others (please specify______)
26. For those who said ‘No’ to (24) above, why do you Not desire to have an HIV test?
I don’t want to know 1. Yes 2. No
I am afraid of the result 1. Yes 2. No
It is not necessary 1. Yes 2. No
I can’t afford it 1. Yes 2. No
Others (Please specify______)
27. Do you know a place in your area where you can have an HIV test? 1. Yes 2. No
28. If ‘Yes’ to (27) above, where (please specify)? ______
29. Have you ever been tested for HIV before? 1. Yes 2. No
30. If ‘Yes’ to (29) above, how long ago was the HIV test done? (Please tick your choice)
Less than 12 months ago
1 to 2 years ago
More than 2 years ago
31. If ‘Yes’ to (29) above, why did you do the test?
It was voluntary 1. Yes 2. No
It was free of charge 1. Yes 2. No
I was forced to do it 1. Yes 2. No
Others (Please specify______)
32. (a.) If ‘Yes’ to (29) above, did you get the result of the HIV test? 1. Yes 2. No
(b.) If ‘No’ to (32a.) above, why (please specify reason)? ______
Personal Risk Perception:
33. Do you feel you have risk of contracting the virus?
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1. Yes 2. No
34. a). How do you rate your chances of being infected with HIV? (please tick your choice)
High chance
Low chance
No risk at all
Already have HIV/AIDS
b). Please give reasons for your answer in (34a). above ______
SECTION C: SEXUAL BEHAVIOUR
35. Have you ever engaged in sexual intercourse? 1. Yes 2. No
36. If ‘Yes’ to (35) above, have you had sex within the last 12 months? 1. Yes 2. No
37. How many sexual partners do you have within the last 12 months (tick as appropriate)?
a) None b) One c) Two d) Others (Please specify)______
38. a) Have you ever heard of Condom before? 1. Yes 2. No
b) Have you ever seen a condom before? 1. Yes 2. No
39. If you have engaged in sex before, have you ever used a condom? 1. Yes 2. No
40. In your sexual acts in the last 12 months, how frequently did you use condoms? 1. Everytime 2. Almost all the time 3. Occasionally 4. Never
41. Did you use condom in the last sexual act with your partner? 1.Yes 2. No
42. Why would you choose to use a condom?
a. To protect myself from HIV/STIs 1. Yes 2. No
b. To protect against unwanted pregnancy 1. Yes 2. No
c. To protect myself from both HIV/STIs and unwanted pregnancy 1. Yes 2. No
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d. Other reasons (please specify______)
43. If you are sexually active and used to use condom but not any longer, why did you stop using condoms?
Did not enjoy using condom 1. Yes 2. No
Wanted a child 1.Yes 2. No
Partner opposed 1. Yes 2. No
Religious reasons 1. Yes 2. No
Other reasons (Please specify______)
44. Have you ever heard or seen a female condom before? 1. Yes 2. No
45. Have you ever engaged in oral sex? 1. Yes 2. No
46. If ‘Yes’ to (45) above, have you had oral sex within the last 12 months? 1. Yes 2. No
47. If ‘Yes’ to (46) above, how frequently do you have oral sex (tick as appropriate)?
e) Once in a month f) Once in a week g) More than once in a week h) Others (Please specify)______
48. Have you ever engaged in anal sex? 1. Yes 2. No
49. If ‘Yes’ to (48) above, have you had anal sex within the last 12 months? 1. Yes 2. No
50. If ‘Yes’ to (49) above, how frequently do you have anal sex (tick as appropriate)?
i) Once in a month j) Once in a week k) More than once in a week l) Others (Please specify)______
SECTION D: STIGMA AND DISCRIMINATION
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51. (a.) Do you know anyone in your community who is HIV positive? 1. Yes 2.
No
(b.) If ‘Yes’ to (51 a.) above, how is the person(s) related to you? (kindly indicate)
A family member/relative
A neighbour in my area
A friend
A teacher in my school or lesson
Others (please specify) ______
52. If ‘Yes’ to (51a.) above, is the HIV positive person looking healthy?
1. Yes 2. No 3. I don’t know
53. How will you relate with a family member who is infected with HIV?
I will be willing to care for the family member. 1. Yes 2. No
I will keep the HIV status of the person a secret. 1. Yes 2. No
I will encourage the family member to openly acknowledge his/her HIV status
(i.e. not to be ashamed in public about HIV status) 1. Yes 2. No
Others (please specify) ______
54. How will you relate with a non-family member who is infected with HIV?
I will be willing to share meals with the person. 1. Yes 2. No
I will be willing to sit beside the person. 1. Yes 2. No
I will buy food from a food seller who is infected with HIV. 1. Yes
2. No
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Others (please specify)______
55. If you find out that your close friend is infected with HIV, would you stop being his/her friend? 1. Yes 2. No
56. Would you agree that a female teacher who is HIV positive should be allowed to teach you in school? 1. Yes 2. No
57. If your classmate is HIV positive would you be:
a) Willing to sit beside the person. 1. Yes 2. No
b) Willing to share writing materials with the person. 1. Yes 2. No
c) Willing to play together. 1. Yes 2. No
d) Willing to share food/meals with the person. 1. Yes 2. No
e) Willing to share toilet with the person. 1. Yes 2. No
f) Others (please specify)
______
58. Would you be willing to help a Support Group (of HIV positive people)? 1. Yes
2. No
59. Would you be willing to participate in a Support Group meeting? 1. Yes 2.
No
60. If you have a friend or family member who is HIV positive, would you be willing to help remind him/her to take the HIV drugs regularly? 1. Yes 2. No
61. (a.) Have you heard of Youth Friendly Clinic? 1. Yes 2. No
(b.) Is any such clinic available in your area? 1. Yes 2. No
62. If ‘Yes’ to (61a.) above, what services do you feel should be available at such a clinic
(please specify)?
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______
______
______
63. If you happen to go for the HIV test and you tested positive for the virus, what would you do next?
a) Seek medical treatment in a hospital. 1. Yes 2. No
b) Go to a church or mosque for treatment. 1. Yes 2. No
c) Tell my close friend about the result. 1. Yes 2. No
d) Tell my parents/guardians about the result. 1. Yes 2. No
e) Tell my teacher about the result. 1. Yes 2. No
f) Plan to infect another person with the virus. 1. Yes 2. No
g) Others (please specify)
______
THANK YOU VERY MUCH!!
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APPENDIX 2: INFORMED CONSENT FORM
This informed consent form is for an HIV/AIDS intervention study entitled: EFFECT OF HEALTH EDUCATION ON HIV/AIDS RISK BEHAVIOURS AND STIGMATIZATION ATTITUDES AMONG ADOLESCENTS IN OGUN STATE, NIGERIA.
Name of Principal OKE, OLALEKAN ADENIYI Investigator Name of National Postgraduate Medical College of Nigeria Organisation Title of Project Effect Of Health Education On HIV/AIDS Risk Behaviours And Stigmatization Attitudes Among Adolescents In Ogun State, Nigeria
There are two parts in this consent form:
1. Information sheet (to share information with you about the research)
2. Certificate of consent (for signatures if you agree to participate in the study)
You will be given a copy of the full Informed Consent Form.
PART I:
Information Sheet
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Introduction
You are cordially invited to volunteer in a research study and this information leaflet is to guide you in making an informed decision to participate. You will be asked some personal questions concerning yourself. In order to participate in this study, you are expected to fully understand what is involved. If you have any questions regarding the study which are not fully explained in this circular, do not hesitate to ask the investigator. You should not agree to participate unless you are completely satisfied about all the procedures involved.
1. The purpose of the study:
HIV/AIDS remain a major health concern in Nigeria (as well as globally) and despite the message about the condition being mentioned in all media outlets, schools, churches/mosques etc. and with the resultant high awareness about it amongst the general population, the scourge remains a major health problem. It is mainly transmitted by sexual intercourse especially between persons of opposite sex (i.e. between male and female) when one partner is HIV positive and they had unprotected sexual intercourse with one another.
This sort of risky behaviour is one of the key drivers of the HIV/AIDS epidemic in Nigeria and is very common among adolescents who possess tendency to engage in (risky) adventurous activities without full understanding of the consequences of such actions.
HIV/AIDS presently has no known cure; hence the mainstay of its control remains prevention especially amongst vulnerable groups in which adolescents belong.
HIV/AIDS positive individuals (i.e. people living with HIV/AIDS - PLWHAs) often suffer stigma and discrimination which causes them not to access care for their condition and this in turn leads to their quick progression to death. Hence efforts should be intensified to reduce stigmatization and discrimination against these individuals in order to improve their quality of life in spite of their HIV positive status so that they may live a healthy normal life and pursue their dreams and goals as others who are not HIV positive.
The study is therefore to assess the effect of a health education training programme on the HIV AIDS risk behaviours as well as stigmatization practices among adolescents in Ogun State.
2. The Procedure and what is expected of you.
This study is in three phases:
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Phase 1:
This is the pre-intervention phase and you will be given a questionnaire to obtain some demographic data about you; also, your level of awareness about HIV AIDS would be assessed in another section of the instrument. Other sections of the questionnaire shall be to assess your sexual behaviours, knowledge and attitude about HIV counselling and testing as well as stigmatization and discriminations against people living with HIV AIDS. This shall constitute the baseline survey.
Phase 2:
There shall be a structured educational programme intervention to address gaps observed in the pre-intervention survey. This shall be a two (2)-day training programme consisting of four (4) modules: (1) knowledge about HIV/AIDS and other STIs; (2) Personal Risk Perception; (3) HIV Status, Stigma and Discrimination and (4) Care and Support and Rights of People Living with HIV/AIDS (PLWHAs). The first two modules i.e. (1) and (2) above shall constitute the training for Day 1; while the latter two modules i.e. (3) and (4) above shall constitute the training for the second day. In each module, multiple health channels will be used and shall consist of health talk by trained peer educators, teacher trained in Family Life and HIV Education (FLHE) and medical personnel about the realities of HIV/AIDS particularly in your environment or community; it shall also consist of role plays, drama and exercises. In addition, the third and fourth modules shall also include interactive sessions with People Living Positively (PLPs) i.e. individuals who are HIV positive within the LGA.
Phase 3:
The outcome of the intervention would be measured to assess its impact among the participants using the same questionnaire that was filled during the pre-intervention phase. This shall be done twice: immediately after the intervention had been concluded, as well as three (3) months after to assess their residual knowledge of the information gained during the intervention training programme.
3. Risk and discomfort involved:
You will not experience any risk or discomfort during the course of the study as there shall be no physical contact with your body during the research.
4. Possible benefits of this study:
There will be no financial benefit (money) in this study. The study is intended to be a capacity building programme for the adolescents in the Local Government. The intervention is aimed at improving their knowledge about HIV AIDS; improve their sexual behaviours (especially promotion of abstinence); and improve their attitude
197 towards people living with HIV/AIDS in their community (i.e. reduction in their stigmatization and discrimination towards HIV positive individuals).
You will also be helping the researcher to understand better, the current trends in adolescents’ sexual behaviours as well as the factors influencing these; also, the study is hoped to provide more information regarding the factors affecting/influencing stigmatization and discrimination attitudes against HIV positive individuals in our community. These information shall be useful in designing further intervention strategies to address similar health challenges in our environment as well as in formulating policies that would specifically address the peculiar health needs of the adolescents in our Local Government (and beyond).
5. Compensation:
There shall be no compensation given for participating in this study.
6. Kindly note that your participation in this study is of your own free will (i.e. voluntary).
7. Kindly note that you can decide to withdraw from the study at any time (of your own choosing) without any negative implications to you whatsoever.
8. Ethical approval:
The protocol for this research has been submitted to the Ethics Committee of the Federal Medical Centre (FMC), Abeokuta and written approvals have been granted by the committee. The study has been structured in accordance with the Declaration of Helsinki (last update: October 2000), which deals with the recommendation guiding researches in health sciences involving human subjects. A copy of these documents may be obtained from the researcher should you so desire.
9. Information:
If you have any further questions or clarifications about this study, you may contact:
. Dr O.A. Oke 07038459086 or [email protected]
If you have any ethical questions about this study, you may contact:
. Chairperson, Ethics Committee of FMC, Abeokuta 08060120281
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. Mr K. Adetumerun, FMC, Abeokuta 08034877387
10. Confidentiality
All information that will be collected from this research shall be kept confidential. Hence, all information you shall provide in the questionnaire shall not have your name on it. The results of the study shall be published in a manner that the participants’ identities remain confidential.
PART II:
Certificate of Consent (Parent/Guardian)
(If not literate, a witness or relative must sign):
I have witnessed the accurate reading of this consent form. I have the understanding of the above information before signing this form. I have had the opportunity to ask questions. I confirm that I am satisfied and all my questions had been answered satisfactorily. I hereby give my consent to allow my child/ward take part in this study by signing this agreement form.
Name of parent or guardian/witness: ______
Signature or Thumb print of parent or guardian/witness:______
Date: Day______Month______Year ______
Statement by Researcher/Person Taking Consent
I have accurately read out the information sheet to the potential participants and to the best of my ability made sure that the participants understand the written information. I confirm that the participants were given an opportunity to ask questions about the study and all the questions asked by the participants have been answered correctly and to the
199 best of my ability. I confirm that the individual has not been coerced into giving consent, and that the consent has been given freely and voluntarily.
Name of researcher/person taking consent: Dr O.A. Oke
Signature of researcher/person taking consent: ______
Date: Day_____Month______Year______
PART III:
Certificate of Consent (Participant)
I have witnessed the accurate reading of this consent form. I have the understanding of the above information before signing this form. I have had the opportunity to ask questions. I confirm that I am satisfied and all my questions had been answered satisfactorily. I have also been made to understand that I can withdraw from further participation in this study whenever I so desire without any negative implications to me whatsoever. I hereby give my consent to take part in this study by signing this agreement form.
Name of participant: ______
Signature/ Thumb print of participant:______
Date: Day______Month______Year ______
Statement by Researcher/Person Taking Consent
I have accurately read out the information sheet to the potential participants and to the best of my ability made sure that the participants understand the written information. I confirm that the participants were given an opportunity to ask questions about the study and all the questions asked by the participants have been answered correctly and to the
200 best of my ability. I confirm that the individual has not been coerced into giving consent, and that the consent has been given freely and voluntarily.
Name of researcher/person taking consent: Dr O.A. Oke
Signature of researcher/person taking consent: ______
Date: Day_____Month______Year______
Appendix 3: Focus Group Discussion Guide
Consent Process Consent forms for focus group participants are completed in advance by all those seeking to participate. Below is a summary of the information in the consent form that focus group organizers and facilitators should use to make sure participants understand the information in the consent form.
Thank you for agreeing to participate. We are very interested to hear your valuable opinion on risk behaviours and stigmatization practices as relates to HIV/AIDS.
The purpose of this study is to learn how adolescents view HIV/AIDS. We hope to learn things that can be done to cater for the peculiar health needs of adolescents especially in the context of HIV/AIDS.
The information you give us is completely confidential, and we will not associate your name with anything you say in the focus group.
We would like to tape (i.e. voice record) the focus groups so that we can make sure to capture the thoughts, opinions, and ideas we hear from the group. No names will be attached to the focus groups and the tapes will be destroyed as soon as they are transcribed.
You may refuse to answer any question or withdraw from the study at any time.
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We understand how important it is that this information is kept private and confidential. We will ask participants to respect each other’s confidentiality.
If you have any questions now or after you have completed the consent form, you can always contact a study team member like me.
Please sign to show you agree to participate in this focus group.
Introduction:
1. Welcome
Introduce yourself and the note-taker/clerk, and send the Sign-In Sheet with a few quick demographic questions (age, gender, family background and if still in school, what class) around to the group while you are introducing the focus group. Review the following: Who we are and what we’re trying to do
What will be done with this information
Why we asked you to participate
2. Explanation of the process
Ask the group if anyone has participated in a focus group before. Explain that focus groups are being used more and more often in health and human services research.
About focus groups We learn from you (positive and negative)
Not trying to achieve consensus, we’re gathering information
No virtue in long lists: we’re looking for priorities
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In this project, we are doing both questionnaires and focus group discussions. The reason for using both of these tools is that we can get more in-depth information from a smaller group of people in focus groups. This allows us to understand the context behind the answers given in the written survey and helps us explore topics in more detail than we can do in a written survey.
Logistics Focus group will last about one hour
Feel free to move around
Where is the bathroom? Exit?
Help yourself to refreshments
3. Ground Rules
Ask the group to suggest some ground rules. After they brainstorm some, make sure the following are on the list. Everyone should participate.
Information provided in the focus group must be kept confidential
Stay with the group and please don’t have side conversations
Turn off cell phones if possible
Have fun
4. Turn on Voice Recorder
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5. Ask the group if there are any questions before we get started, and address those questions.
6. Introductions
Go around table
Discussion begins, make sure to give people time to think before answering the questions and don’t move too quickly. Use the probes to make sure that all issues are addressed, but move on when you feel you are starting to hear repetitive information.
Questions:
1. What do you know about HIV/AIDS?
Follow-up: how is it transmitted? How can one prevent HIV infection?
2. a. Which types of sexual activity do you know?
b. Which of these types of sexual activity do you feel can spread HIV and why do you think so? c. How many of your friends are sexually active (you may also comment on their preference for condom use)? d. What are your opinions about condom use?
3. a. Do you feel you can be infected with HIV? Why do you feel this way?
b. What sort of activities do you feel can make you get infected with HIV?
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4. a. Why do you feel it is important for a person to know his/her HIV status?
b. If any of you has ever gone for an HIV test, what was the experience like?
5. a. Do you know and have you met anyone who is HIV positive before?
b. Please describe your reaction the moment you got to know that s(he) has HIV. c. If you discover that you’ve just tested positive for HIV, how would you react? d. In your opinion, how should people living with HIV be treated in society?
6. a. What special health needs do you think you have as an adolescent (as different from older adults)?
b. How are the health facilities in your area able to meet these needs?
That concludes our focus group. Thank you so much for coming and sharing your thoughts and opinions with us. We have a short evaluation form that we would like you to fill out if you time. If you have additional information that you did not get to say in the focus group, please feel free to write it on this evaluation form.
Materials and supplies for focus groups Sign-in sheet
Consent forms (one copy for participants, one copy for the team)
Evaluation sheets, one for each participant
Name tents
Pads & Pencils for each participant
Focus Group Discussion Guide for Facilitator
1 recording device
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Batteries for recording device
Permanent marker for marking tapes with FGD name, facility, and date
Notebook for note-taking
Refreshments
APPENDIX 4: OGUN STATE SENATORIAL ZONES AND LGAs
Ogun West (5 LGAs) –
Ipokia LGA, Yewa-South LGA, Yewa-North LGA, Ado-Odo/Ota LGA and Imeko-Afon
LGA.
Ogun Central (6 LGAs) –
Odeda LGA, Obafemi-Owode LGA, Ifo LGA, Ewekoro LGA, Abeokuta-North LGA and
Abeokuta-South LGA.
Ogun East (11 LGAs) –
Remo-North LGA, Sagamu LGA, Ikenne LGA, Odogbolu LGA, Ijebu-Ode LGA, Ijebu-
North LGA, Ijebu North-East LGA, Ijebu-East LGA and Ogun Waterside LGA.
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APPENDIX 5: LIST OF WARDS IN SELECTED LGAs
Ado-Odo/Ota Local Government: 16 wards.
1. Ado 1
2. Ado 2
3. Agbara
4. Alapoti
5. Atan
6. Ejila
7. Ere
8. Igbesa
9. Ijoko
10. Iju
11. Ilogbo
12. Ketu
13. Ota 1
14. Ota 2
15. Ota 3
16. Sango.
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Ifo Local Government (11 wards):
1. Agbado
2. Agosi
3. Akute/Ajuwon
4. Coker/Ilepa
5. Ibogun
6. Ikorita/Okenla
7. Ojodu/Isheri
8. Oke-Aro/Ibaragun
9. Olose
10. Oyero/Ososun
11. Sunren.
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APPENDIX 6: WORKPLAN OF ACTIVITIES
S/ Activities Timeline Estimated Remark N Cost (N : K)
1. Advocacy visit to LGA Mgt. 2nd week in No anticipated cost
(to obtain LGA permission) Feb. 2014
2 Constituting research team 3rd week in No anticipated cost
(5 trained assistants) Feb. 2014
3 Seeking ethical approval Mar. – April Ethical Committee review fee = 2014 10,000.00
4 Seeking approval of College April – Jun. Proposal fees for part 2 fellowship research 2014 project =
20,000.00
5 Printing of materials: a) & b) = 5,000.00; a) Consent forms (parents) 2nd week in Jun.
INTERVENTION PHASE 2014 10,000.00 for IEC b) Consent forms (participants) materials
- c) Training (IEC) materials Total = 15,000.00
6 a) Selection of the 2 LGAs & 2 wards each 3rd week in Nov. No anticipated cost for study 2014
PRE (intervention & control) 3,000.00 b) Planning meeting of research team
7 Selection of the participants: No anticipated cost for
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a) Advocacy to Town Planning Authorities (a) & (b).
b) Advocacy to community leaders in 3rd week in Nov. Logistics cost for 2014 sampling exercise: the two selected wards of each LGA. 1st & 2nd week in Writing materials = c) Sampling exercise in the 2 wards each of Dec. 2014 6,000.00 the 2 LGAs Transport.(@ 10,000/ward) = 10,000 x 4 = 40,000.00
Total = 46,000.00
8 Obtaining informed consent of Parents/Guardians 1st & 2nd week in No anticipated cost Dec. 2014
9 Obtaining informed consent of participants 1st & 2nd week in No anticipated cost Dec. 2014 1 Focus Group Discussion (FGD) session to be Tape recorder (with conducted in each of the 4 wards extra tapes) = 10,000.00,
Writing materials = 5,000.00
Refreshments = 2,000 per FGD = 8,000.00.
Total = N23,000.00
10 Pre-testing of research instrument 2nd week in Dec. No anticipated cost 2014 (30 Questionnaires)
11 Correction of research instrument (where 2nd week in Dec. No anticipated cost necessary) 2014
12 Printing of research instruments 3rd week in Dec 35,000.00 2014 (on a large scale) i.e. 2000 copies
13 Securing the two (2) venues for the study 3rd week in Dec No anticipated cost 2014
14 Research team planning meeting: to harmonise 3rd week in Dec Refreshment = 2014 5,000.00 strategies before the study e.g. reminders to Reminders to participants (or their parents) etc. parents/participants:
sms/calls = 20,000
Total = 25,000.00
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15 Mobilisation of resources for the study to the 3rd week in Dec. Transport logistics = venues 2014 10,000.00
16 Conduct of baseline survey for Control & 2ndt week in Jan. Baseline survey Intervention 2015 (Control grp):
Groups: Refreshments (290) @ 150.00 each = Refreshments for participants 43,500.00
(to serve as Day 1 refreshments for intervention Day 1 (Intervention): grp.) Refreshments (290) @ 250.00 each = 72,500.00
Total = 116,000.00 INTERVENTION PHASE
1 Mobilise training materials to venue: 2nd week in Jan. 2015 Transport logistics = 10,000.00 Includes transport logistics
2 Training of participants (2 Days) 2nd week in Jan. 2015 Refreshments (290) @ 250.00 3 Refreshments for participants (Day 2) 2nd week in Jan. 2015 each = 72,500.00
4 Feedback from participants 2nd week in Jan. 2015 Hiring of public address system @ 5,000/day x 2 days = 10,000.00
Miscellaneous = 5,000.00
Total = 87,500.00
POST - INTERVENTION PHASE
1 Immediate post-intervention: 2nd week in Jan. 2015 No anticipated cost
Evaluation of participants’ gain from the training using same questionnaire as for the baseline survey
2 Review meeting of research team: to appraise 2nd week in Jan. 2015 Refreshment = 3,000.00 performance/conduct of the study
3 4 months post-intervention: 2nd week in April 2015 Refreshments = (a); 3,000.00
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a) Planning meeting of research team 1st – 3rd weeks in April Reminders to 2015 (b) & (c); parents/participants: b) Reminders to participants (visitation or calls/sms) 2nd week in May 2015 sms/calls = 15,000 (d - f). Transport logistics = c) Securing the two (2) venues for the study 10,000.00 d) Mobilise materials to the venues Refreshments (290 x 2) e) Conduct the post-intervention survey (control @ 150.00 each = and intervention groups) 87,000.00
f) Refreshments for the surveys Total = 115,000.00
4 Data Management & Analysis: 3rd week in May – 3rd To be determined week in June 2015 a) Sorting of filled questionnaires
b) Data entry
c) Data analysis
5 Report writing July 2015 Preparation of 4 copies of report = 10,000.00
6 Feedback to the participants & other stakeholders on 3rd & 4th weeks in July No anticipated costs findings from the study 2015
7 Appreciation to all stakeholders: 2nd week in Aug. 2015 No anticipated costs
a) Writing of appreciation letters
b) Advocacy visit to stakeholders
8 Miscellaneous expenses: e.g. Concurrent @ 20,000.00 per assistant = 5 x 20,000.00 a) Stipends to research assistants = 100,000.00
GRAND TOTAL = 628,500.00
Hence a tentative minimum estimated total cost of N 628,500.00 (six hundred and twenty-eight thousand five hundred naira) only is anticipated for this study.
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