Early determination of human immunodeficiency virus status by routine voluntary counseling and testing in benin city, Nigeria.

BACKGROUND: To reduce the burden of human immunodeficiency virus (HIV), the popularization of voluntary counseling and testing (VCT) for early determination of human immunodeficiency virus status will be of immense benefit. AIM: To evaluate the uptake of voluntary counseling and testing and sero-prevalence of human immunodeficiency virus among status naïve outpatients and self-presenting VCT clients in Benin City, Nigeria.
MATERIALS AND METHODS: This study was carried out in the period of May 2010 to April 2011 at the University of Benin teaching hospital, Benin City. Subjects who consented were included and screened for HIV. Pre and post-test counseling was done following the world health organization guidelines.
RESULTS: Out of 10,533 subjects (7783 outpatients and 2750 self-presenting VCT clients) counseled for VCT, a total of 4651(44.2%) subjects; (3971(51.0%) outpatients and 680 (24.7%) self-presenting VCT clients), consented and accepted HIV VCT. Overall HIV prevalence was 6.4%. 270 (6.8%) outpatients and 29 (4.3%) self-presenting VCT clients were HIV positive. HIV was significantly associated with female gender among the outpatients (P<0.001).
CONCLUSION: VCT uptake was low; the sero-prevalence of HIV was high. The need to employ an expanded and more purpose oriented public enlightenment campaign on the usefulness of HIV VCT should be a priority for HIV control agencies in our area.

Introduction

Human immunodeficiency virus (HIV) continues to be a major public health problem worldwide. It is also the etiological agent of the dreaded acquired immune deficiency syndrome (AIDS).[12] AIDS was first recognized in 1981 by the center for disease control (CDC) among five homosexual men in Los Angeles, United States,[3] since then a gradual spread has occurred and is now found in all parts of the world with the Sub-Saharan Africa being the epicenter of the disease burden.[4] Epidemiological data has identified sexual intercourse, intravenous drug use, blood transfusions and mother to child transmission as the main route of HIV transmission.[5]

HIV was first recognized in Nigeria in 1986.[6] At present, Nigeria is known to have the highest number of people living with HIV after South Africa.[7] Population survey of HIV by the federal ministry of health (FMOH) puts Nigeria's HIV prevalence at 3.6%.[8] A 2008 sentinel HIV survey in pregnant women reported 4.6% prevalence.[910] At present the FMOH has estimated that 2.98 million people are living with HIV in Nigeria.[11]

Early diagnosis of HIV through voluntary counseling and testing has been recognized by the World health organization as a major tool to reduce HIV mortality and spread.[12] Voluntary counseling and testing (VCT) has been defined as a patient or client initiated counseling and testing in which patients undergo confidential counseling to enable an individual to make an informed choice learning his or her HIV status and to take appropriate action.[13] HIV VCT is an agent of the needed prompt, medical, social, mental and legal care for individuals who tested positive and serves as a medium of social behavior reengineering for individuals who tested negative.

At present, HIV voluntary counseling and testing is one of the major policy initiatives of government aimed at reducing HIV burden in Nigeria. The FMOH of Nigeria has set up various clinical and population based survey and treatment plans for effective control of HIV epidemic.[14] Despite Government's commitment to HIV/AIDS control, there still exists significantly a large portion of at risk individuals in Nigeria whose HIV status remains a mystery to them. This study thus aimed to evaluate VCT uptake and sero-prevalence of HIV among status naive outpatients and self-presenting VCT clients attending the general practice clinic and VCT center of University of Benin teaching hospital, Benin City, Nigeria.

Materials and Methods

Study area

This hospital based study was carried out at the VCT center and general practice clinic of the University of Benin teaching hospital (UBTH), Benin City, Nigeria from the period of May 2010 to April 2011. UBTH is a federal tertiary hospital with a referral status. Benin City popularly referred to as the ‘cradle of black civilization’ by its indigenes is the capital of Edo state, Nigeria and has an estimated population of 1,147,188.[15]

Our VCT centre

The HIV VCT program co-sponsored by the federal Government and the president's emergency plan for AIDS relief (PEPFAR) was started in UBTH in 2006 rendering, counseling and free testing for patients and self-presenting VCT clients. The VCT center is located in the general practice clinic of the hospital. Recent guidelines of the world health organization on conducting HIV VCT[16] is used in our center. Informed consent (either verbal or written) is a requirement for participating in HIV VCT and confidentiality is made a custom with regard to test results and other details of clients.

Subjects

The study included two groups of subjects; Outpatients and self-presenting VCT clients. Outpatients included subjects who were HIV status naïve and having no history of immunosuppression and were presenting to the general practice clinic for medical care; they were on first visit (first booking) with symptoms ranging from mild prodromal symptoms to symptoms like diarrhea and other non-specific clinical symptoms. The other subject group included self–presenting VCT clients who were apparently healthy individuals attending the VCT center for HIV VCT.

Methods

Pre-test and post-test counseling was done by counselors using the WHO guidelines.[16] Verbal consent was received from the subjects and they were included in the study. Exclusion criteria were history of HIV and knowledge of HIV status. Questionnaire was administered by a nurse counselor to obtain information on bio-data and socio-demographic parameters. The protocol for the study was approved by the ethical committee of university of Benin, teaching hospital, Benin City.

To evaluate uptake of VCT, outpatients who accepted VCT was calculated against overall patients received who met the criteria for inclusion in the study and among the self-presenting VCT clients, uptake of VCT was determined against number of clients presenting for VCT who were counseled and actual number of them who went for HIV testing.

Sample collection

Blood samples were collected aseptically by vein-puncture from subjects and were analyzed for sero-antibodies to HIV-1 and 2.

Sample analysis

Sample analysis was done at the medical laboratory at the General practice clinic UBTH, Benin City. Determine® HIV-1/2 Test cards (Trinity Biotec, Ireland) and HIV -1/2 Stat-Pak® Assay (Chembio D S, USA) were used in a stepwise order for the detection of HIV 1 and HIV-2 in the blood. These methods which are immunochromatographic and qualitative in nature, detect the presence of antibodies to HIV-1 and HIV-2 in human blood and can be read in vitro having more than 99.9% sensitivity and 99.75% specificity.

Statistical analysis

The effect of age and sex on the sero-positivity for HIV among outpatients and self-presenting VCT clients were tested statistically using chi-square with Statistical packages for social sciences (SPSS) V. 15 and P<0.05 was taken as significant.

Results

A total of 4651 subjects (3971 outpatients and 680 self–presenting VCT clients) out of overall 10533 (7783 outpatients and 2750 self-presenting VCT clients) counseled, consented and met the criteria for inclusion in the study. Overall percentage uptake of VCT was 44.2%. Uptake of VCT among outpatients and self-presenting clients for VCT was 51.0 and 24.7% respectively. A total of 6.4% of the subjects studied were positive for HIV. 270 (6.8%) out of 3971 outpatients and 29 (4.3%) out of 680 self-presenting VCT clients were HIV sero-positive. Females were more positive for HIV in both groups studied [Table 1]. HIV was significantly associated with gender among the outpatients (P<0.001). Gender was not a significant determinant in HIV seropositivity in self-presenting VCT clients. Age was not associated with HIV sero-prevalence in both groups [Table 1].

Table 1

Prevalence of HIV in outpatients and self-presenting VCT clients

Distribution of HIV with socio–demographic factors (Level of Education, Occupation and Marital status) was studied in both subject groups. HIV sero-prevalence was higher amongst outpatients with or undergoing tertiary level of education (12.6%), students (8.2%) and married (8.4%). Among self-presenting VCT clients, HIV sero-prevalence was higher in individuals with or undergoing tertiary level of education (4.4%), students (5.1%) and divorced (25.0%) [Table 2].

Table 2

HIV sero-prevalence in relation to sociodemographic characteristics

Discussion

This study presents the risk of HIV in a population of status naïve outpatients and self-presenting VCT clients accessing the HIV VCT center of University of Benin teaching hospital. Overall sero-prevalence of 6.4% for HIV was recorded. The prevalence report of this study is higher than the median average of 5.2% for Edo state, which Benin City is capital of.[9] The prevalence report of this study is quite higher than 5.39% reported by Akhigbe et al.,[17] in VCT centers in Kwara state, Nigeria, but less than 19.2 and 25% reported in Ghana and Uganda respectively.[1819] Variation in biological factors and rate of exposure to risk factors has been known to impact on the heterogeneity in HIV epidemic.[20]

Overall uptake of VCT in this study was 44.2%. The rate of acceptance of VCT in this study was lower than in previous reports; 98% accepted VCT in Uganda,[19] 47% in Cape Town, South Africa,[21] 62.2% in Rakia, Uganda[22] and 100% in Ethiopia.[23] The rate of acceptance of VCT in Nigeria is associated with the study population. 0.57% VCT uptake was reported in a multicenter study in Kwara state.[17] Higher VCT acceptance is commonly found in pregnant women in Nigeria, 81.0% and 96.1% accepted VCT in Kano and Lagos respectively.[2425] Low rates of VCT acceptance in youths is a common finding in Nigeria.[26] Yahaya et al.,[26] recently studied the factors militating against acceptance of VCT among youths in Nigeria, ignorance of VCT and fear of being positive ranked top. Though, Duniyam et al.,[27] reported a high acceptance rate of 50.7% among medical students in Jos Nigeria, it should be noted that the study population used represent a sect of youth well equipped with the knowledge of advantage of knowing one's HIV status.

VCT uptake in our study was higher among outpatients than in self-presenting VCT clients (51.0% and 24.7% respectively). Though the possible hindrances to acceptance of VCT was not studied, it should be noted that the higher VCT uptake among outpatients may be consequent of their medical condition who can be easily convinced to go for HIV VCT to help facilitate their treatment. Recently, physicians do request for HIV VCT in outpatients on first booking before proceeding for further treatment to rule out a possibility of HIV infection.

Female outpatients significantly had a higher sero-positivity for HIV when compared to their male counterparts (P<0.001), though gender didn’t play a role in sero-positivity for HIV in self -presenting VCT clients. This is in agreement with the survey of the federal ministry of Heath.[9] Female gender has been known to possess higher chance of infection with HIV due to their biological vulnerability, higher incidence of sexually transmitted diseases and hormonal changes.[28] No difference was observed in HIV sero-prevalence in the age groups studied. In our outpatients, HIV sero-prevalence was higher amongst individuals with or undergoing tertiary level of education (12.6%), among students (8.2%) and married (8.4%). In self-presenting VCT clients, HIV sero-prevalence was higher in individuals with or undergoing tertiary level of education (4.4%), students (5.1%) and divorced (25%). Outpatients that were married and had a higher level of education had the highest prevalence of HIV; similar finding has been reported in a previous study.[29] Majority of self-presenting VCT client in this study are young, the higher prevalence of HIV in the divorced may explain for risky sexual practices they are involved in during separation.

Conclusion

HIV sero-prevalence was studied in status naive outpatients and self-presenting VCT clients; overall HIV sero-prevalence was 6.4%. Overall Percentage uptake of VCT in our center was 44.2%. The need to employ an expanded and more purpose oriented public enlightenment campaign on the usefulness of HIV VCT should be the present focus of agencies of government involved in HIV control in Nigeria. VCT should be made a custom for an effective control of HIV spread in areas of generalized HIV epidemic such as Nigeria.