Acceptability of Voluntary Counselling and Testing For HIV among Pregnant Women in Western Health Division, the Gambia Thesis submitted by: ABDOU JAMMEH As partial fulfilment for the award of the Master of Philosophy Degree (MPhil) in International Community Health Supervisor: PROFESSOR JOHANNE SUNDBY University of Oslo, Norway Faculty of medicine Department of General Practice and Community Medicine Section for International Health MAY 2005 TABLE OF CONTENTS ABSTRACT……….............................................................................................................6 DEDICATION…….............................................................................................................8 ACKNOWLEDGEMENT...................................................................................................9 ACRONYMS…….............................................................................................................10 CHAPTER 1: INTRODUCTION.................................................................................. 12 1.1. INTRODUCTION ..................................................................................................12 1.2. PROBLEM STATEMENT.....................................................................................13 1.3. PROFILE OF THE GAMBIA ................................................................................14 1.3.1. Geography........................................................................................................14 1.3.2. Population and Demographic Characteristics..................................................15 1.3.3. Economy ..........................................................................................................16 1.3.4. Health Services ................................................................................................17 1.3.4.1. Health policy .............................................................................................17 1.3.4.2. Population Policy and Programme ..........................................................17 1.3.4.3. Policies and guidelines on HIV / AIDS .....................................................18 1.3.4.4. Organization and Administration .............................................................19 1.3.4.5. Human Resource for Health .....................................................................20 1.3.4.6. Maternal and Child Health (MCH) Care Services ..................................21 1.3.4.7. User fees....................................................................................................22 CHAPTER 2: LITERATURE REVIEW...................................................................... 23 2.1. EPIDEMIOLOGY OF HIVAIDS AND MTCT.....................................................23 2.2. GLOBAL ISSUES OF HIV\AIDS .........................................................................23 2.3. BREASTFEEDING AND HIV INFECTION ........................................................24 2.4. ANTIRETROVIRAL THERAPY ..........................................................................25 2.5. OVER VIEW OF VOLUNTARY HIV COUNSELLING AND TESTING (VCT) ........................................................................................................................................27 2.5.1. Stigma and discrimination...............................................................................28 2.5.2. Uptake of VCT service ....................................................................................28 2.5.3. VCT in Antenatal Clinic - entry point for comprehensive care for pregnant women........................................................................................................................29 2.5.4. Minimum conditions for providing VCT in antenatal settings........................31 2.5.4.1. Acceptability, accessibility and affordability of service .................................... 31 2.5.4.2. Additional space to ensure privacy...........................................................31 2.5.4.3. Adequate numbers of qualified staff .........................................................31 2.5.5. Models of HIV Voluntary Counselling and Testing Service Delivery............32 2.5.5.1. Stand-alone (direct sites or free standing model) .....................................32 2.5.5.2. Private sector model .................................................................................32 2.5.5.3. Public sector / NGO-based model: ...........................................................33 2.5.5.4. Integrated model within existing facilities................................................33 2.5.6. Voluntary Counselling and Testing in the Gambia..........................................34 CHAPTER 3: PURPOSE OF STUDY, OBJECTIVES, JUSTIFICATION AND STUDY SETTING. ......................................................................................................... 37 3.1. PURPOSE OF THE STUDY ..................................................................................37 3.2. SPECIFIC OBJECTIVES.......................................................................................37 3.3. JUSTIFICATION OF THE STUDY ......................................................................37 3.4. STUDY AREA/SETTING......................................................................................38 3.4.1. Population and Demographic Characteristics......................................................39 CHAPTER 4: STUDY METHODOLOGY .................................................................. 41 1 4.1. STUDY DESIGN....................................................................................................41 4.2. STUDY POPULATION.........................................................................................41 4.2.1. Inclusion Criteria..............................................................................................42 4.2.2. Exclusion Criteria ............................................................................................42 4.3. SAMPLE SIZE AND SELECTION.......................................................................42 4.4. DATA COLLECTION PROCEDURE...................................................................43 4.4.1. Preparation for data collection .............................................................................43 4.4.2. Data collection.....................................................................................................44 Approach used and instrument /tool......................................................................44 4.4.3. Data handling.......................................................................................................45 4.4.4. Operational definitions.........................................................................................45 4.4.5. Data analysis ........................................................................................................47 4.4.6. Ethical consideration............................................................................................48 CHAPTER 5: FINDINGS.............................................................................................. 49 5.1. SOCIO-DEMOGRAPHIC CHARACTERISTICS ................................................49 5.2. KNOWLEDGE ABOUT HIV / AIDS and MTCT.................................................49 5.2.1. Level of knowledge on three common ways HIV is spread............................49 5.2.2. Level of knowledge on three ways HIV can be transmitted from mother to child............................................................................................................................50 5.2.3 Level of knowledge on three basic ways HIV can be prevented-ABC messages ....................................................................................................................................51 5.2.4 Misconception relating to HIV transmission ....................................................51 5.2.5 Perceived susceptibility to HIV infection ........................................................52 5.3. ISSUES ON VOLUNTARY HIV COUNSELLING & TESTING........................52 5.3.1. Awareness of PMTCT programme..................................................................52 5.3.2. Source of information on PMTCT programme ...............................................52 5.3.3. Voluntary Counselling and Testing .................................................................53 5.3.3.1. Uptake of service (HIV testing )................................................................53 5.3.3.2. Decision making toward HIV testing........................................................54 5.3.3.3. Association between actual HIV testing and some socio-demographic variables.................................................................................................................55 5.3.3.4. Return for HIV test result..........................................................................56 5.3.3.5. Intend disclosure of sero-status ................................................................56 5.3.3.6. Introduction of HIV testing in antenatal clinics.......................................58 5.3.3.7. Agreement and disagreement on statements on the Impact of HIV testing on the quality of care offered to women.................................................................59 5.3.3.8. Views of respondents concerning the pre-test counselling process .........59 5.3.3.9. Perceive Barriers / obstacles to effective