Acceptability of HIV/AIDS testing among pre-marital couples in Iran (2012).

BACKGROUND: Human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) is a lifestyle-related disease. This disease is transmitted through unprotected sex, contaminated needles, infected blood transfusion and from mother to child during pregnancy and delivery. Prevention of infection with HIV, mainly through safe sex and needle exchange programmes is a solution to prevent the spread of the disease. Knowledge about HIV state helps to prevent and subsequently reduce the harm to the later generation. The purpose of this study was to assess the willingness rate of couples referred to the family regulation pre-marital counselling centre for performing HIV test before marriage in Yazd. PATIENTS AND METHODS: In this descriptive study, a simple random sampling was done among people referred to Akbari clinic. The couples were 1000 men and 1000 women referred to the premarital counselling centre for pre-marital HIV testing in Yazd in the year 2012. They were in situations of pregnancy, delivery or nursing and milking. The data were analyzed using Statistical Package for the Social Sciences (SPSS) software and chi-square statistical test.
RESULTS: There was a significant statistical difference between the age groups about willingness for HIV testing before marriage (P < 0.001) and also positive comments about HIV testing in asymptomatic individuals (P < 0.001). This study also proved a significant statistical difference between the two gender groups about willingness to marry after HIV positive test of their wives.
CONCLUSION: The willingness rate of couples to undergo HIV testing before marriage was significant. Therefore, HIV testing before marriage as a routine test was suggested.

INTRODUCTION

Infection with human immunodeficiency virus (HIV) has remained an important public health problem.1234

Testing for HIV infection has been an important preventive strategy, and in 2006, the Centers for Disease Control and Prevention (CDC) published revised guidelines for performing HIV testing in health care settings.5

It was estimated by World Health Organization (WHO) that by the end of 2007, 33.2 million people would be HIV infected. According to the WHO, currently 34 million people are living with HIV infection.6

HIV/acquired immune deficiency syndrome (AIDS) is a global pandemic. Of 34 million people affected by HIV worldwide, approximately 17.2 million are men, 16.8 million are women and 3.4 million are aged less than 15 years. There were about 1.8 million deaths from AIDS in 2010, down from 2.2 million in 2005.7

The mortality rate due to HIV in several regions of Asia (south and south east) with population about 2 billion has been about 250,000 deaths in 2010. During 2001-2005, the men had the highest transmission risk conducts via sex (40-49% of cases).8

Today, most of the cases worldwide are due to sexual contact, intravenous drug injection and some cases of vertical transmission from mother to child during breast feeding in developing countries.9

Over the years, recommendations for HIV testing among women have evolved from initial testing offered especially to those identified as high risk to broader voluntary counselling and testing (VCT).10

HIV continues to spread rapidly around the world; particularly in developing countries. Asia has now become an epidemic centre, with a rapidly increasing rate of HIV transmission.11

A delay in the detection and management of HIV infection is directly linked to death, as many individuals and their health-care providers do not perceive themselves as at-risk persons.121314

HIV infection has been investigated in Iran, Lebanon, Morocco and Saudi Arabia; it is common in Iran among prisoners, children, sex workers and injecting drug users.131415

Arulogun et al. used a questionnaire for obtaining of the data from 571 unmarried couples.16

A study investigated the willingness rate of couples wishing to be married to perform pre-marital HIV testing in China.17 Screening for HIV-1 became mandatory for both — to — be husband and wife in Saudi Arabia as a prerequisite for issuing marriage certificate.18

In our country, Tehran, the first patient was discerned in 1987 who had received infective clotting factors.19

As regards HIV testing because of its ethical considerations, is not mandatory in our country and pre-marital infectious tests such as syphilis are mandatory.19 Even though pre-marital HIV testing is not mandatory, this study aimed to assess the willingness rate of couples referred to the family regulation pre-marital counselling centre for performing HIV detection test before marriage in Yazd. This is important for the purpose of influencing policy decisions and for prevention interventions.

PATIENTS AND METHODS

The study was descriptive and cross-sectional in design in which a simple random sampling (census) was done among young couples referred to the pre-marital counselling centre. The couples included 1000 men and 1000 women referred to the mentioned centre.

This study assessed the willingness rate of young couples divided in three groups: Aged less than 20 years, 20-29 years and above 29 years and referred to the counselling centre for pre-marital HIV testing in 2012 in Yazd.

The ethics committee of Shahid Sadoughi University of Medical Sciences approved the study. The confidentiality of information was explained to the participants.

The sample size was determined based on the following formula:

P was considered 0.5 and d (5-20% of P) is the desired level of precision. By considering, z = 1.96, the sample size was determined. Considering the error of 3%, 1000 cases was required, and because the results of estimation about both sexes are important, overall, 2000 cases (1000 men and 1000 women) were investigated.

Data were collected using a questionnaire. The questionnaire contained eight questions.

The following parameters were used in the questionnaire: Age, gender, belief that asymptomatic people needed to HIV testing, the willingness to marry if HIV test of wife was positive, belief that HIV is preventable and belief that partners should know positive result of pre-marital HIV testing.

Reliability and validity of the questionnaire were investigated with the help of experts and Cronbach's alpha test.

All the questionnaires were filled and completed by the couples themselves and if they were illiterate, they were filled by the help of the main investigator.

Statistical analysis was performed using Statistical Package for the Social Sciences 16.0 (SPSS Inc., Chicago, IL, USA). P < 0.05 was accepted as significant.

Positive attitude towards mandatory pre-marital HIV testing was coded as ‘1’, whereas negative attitude was coded as ‘0’.

RESULTS

In this study, all premarital couples (100%) who were literate answered the questionnaire. The limitations included limited financial resources, people access to complete information and limitations in telling the truth.

The couples, 1000 men and 1000 women, were referred to the pre-marital counselling centre.

Of these 2000 participants, 23.3% lived in rural and 76.7% in urban areas.

The age groups consisted of three groups: Aged less than 20 years, 20-29 years and over 29 years. Of these 2000 participants, 122 cases (40.9%) were in the under 20 years group, 866 cases (59.8%) in the 20-29 years group and 176 cases (69.3%) in the over 29 years group; overall, 1164 cases (58.2%) were willing to pre-marital HIV testing. There was a statistically significant difference between age groups regarding their willingness to pre-marital HIV testing (P < 0.001) [Table 1].

Table 1

Frequency of couples’ willingness for pre-marital HIV screening based on age

Of these 2000 participants, 204 cases (68.5%) were in the under 20 years group, 1006 cases (69.5%) in the 20-29 years and 170 cases (66.9%) in the over 29 years group; Overall, 1380 cases (69.0%) were willing to perform HIV testing before marriage, even if it was to be paid by them. There was a statistically significant difference between the age groups (P = 0.141).

Of these 2000 participants, 148 cases (49.7%) were in the under 20 years group, 778 cases (53.7%) in the 20-29 years group and 146 cases (57.5%) in the over 29 years group; overall, 1072 cases (53.6 %) believed that asymptomatic people needed HIV testing. There was a statistically significant difference between age groups (P < 0.001) [Table 2]. Of these 2000 participants, 297 cases (29.7%) were men and 237 (23.7%) were women; overall, 534 cases (26.7%), were willing to marry if HIV test of their wife was positive. There was a statistically significant difference between the two groups (P = 0.002) [Table 3]. Of these 2000 participants, 648 cases (64.8%) were men and 648 (64.8%) were women; overall, 1296 cases (64.8%) believed that HIV is preventable. There was not a statistically significant difference between the two groups (P = 0.734) [Table 4].

Table 2

Frequency of couples’ opinion about pre-marital HIV screening in asymptomatic individuals based on age

Table 3

Frequency of couples’ willingness to marriage if test result related to their partner was positive (based on gender)

Table 4

Frequency of couples’ opinion about prevention of HIV based on gender

Of these 2000 participants, 658 (65.8%) were men and 722 (72%) were women; overall 1380 (69.1%) people had a desire to know the status of tests of their partners. There was a statistically significant difference between the two groups (P = 0.007).

High percentages of participants would notify their families in the event of a positive test result (675 (67.2%) men, 687 (68%) women).

Of these 2000 participants, 791 cases (79.1%) were men and 767 (76.7%) were women; overall, 1558 cases (77.9%) believed that their partners should know positive result of pre-marital HIV testing. There was no statistically significant difference between the two groups regarding awareness of partners about positive result of HIV testing (P = 0.201) [Table 5].

Table 5

Answer of the HIV positive couples about awareness of their wife from positive result of pre-marital HIV testing

DISCUSSION

Our results showed a significant difference between the age groups about willingness for HIV testing before marriage and also positive comments about HIV testing in asymptomatic individuals. This study also approved a significant difference between the two gender groups about willingness to marry after HIV positive test of their wives.

In 2010, Arulogun et al. used a questionnaire for obtaining the data from 571 unmarried couples. The mean age of cases was 20.6 ± 2.6 years, 48% were females. Overall, 82.8% of them believed that pre-marital HIV testing should be done.16

Wu et al. investigated the willingness rate of couples wishing to be married to perform pre-marital HIV testing in China. In general, 1588 participants came to the hospitals or health centres for marriage counseling during the study period. Overall, 16.4% (13.2% men, 19.7% women) believed that mandatory pre-marital HIV testing should be performed.17 In our study, willingness rate of men to pre-marital HIV testing was more than women (62.2% men, 54.2% women).

Our results were nearly the same as that of the Nigerian study, whereas there was a clear difference between our results and that of the China study. In addition, in our study's willingness rate of men to pre-marital HIV testing was more than women, whereas it was reverse in China.

In a study, screening for HIV-1 became mandatory for both-to-be husband and wife in Saudi Arabia as a prerequisite for issuing marriage certificate. Most heterosexually infected women (97%) acquired the virus from their husbands.18

Similarly, a descriptive study was conducted on pre-marital HIV screening programme in Johor over a 3 year period. As a result, 123 new HIV cases were detected (0.17%) from 74, 210 respondents. Of the 123 HIV cases, 97 (78.9%) were males and 26 (21.1%) were females who were willing to pre-marital HIV testing. Of 36 cases detected, only 1 case occurred in the age group of under 20, whereas the age group of 30-39 recorded the highest occurrence with 13 cases (36.1%).20

A descriptive cross-sectional study was conducted among prospective couples referred from faith-based organisations in Nigeria for pre-marital HIV screening. The willingness for pre-marital HIV testing was significantly higher among females 23 (27.4%) than males 12 (14.3%). Infection rate was highest in the 25-29 years group and lowest in the 35-39 years group, although this difference was not statistically significant (P = 0.058).21 But there was a significant statistical difference between the age groups about willingness for HIV testing before marriage in the present study. In our study, willingness rate of men to pre-marital HIV testing was more than that of women (62.2% against 54.2%, respectively).

A study determined the acceptance of routine testing and counselling for HIV at the medical emergency unit at a national referral hospital in Kampala, Uganda. It was performed among 233 adult patients who were offered HIV testing. The median age of the study population was 32 ± 14 years. Most participants were Christians and more than half (56%) were females. Of the 208 eligible for HIV testing, 95% accepted for test.22 Similarly, willingness rate of couples in our study for pre-marital HIV testing was 58.2%.

CONCLUSIONS

According to the results, the willingness rate of couples for HIV testing before marriage was significant. Therefore, HIV testing before marriage as a routine test was suggested. Religious beliefs were one of the major limitations in this screening programme.