Abstract
Background:
The purpose of establishing integrated counseling and testing center (ICTC) is to detect HIV at the earliest time, providing information on modes of transmission and prevention of HIV by promoting behavioral change and reducing vulnerability, and informing individuals on HIV prevention, care, and treatment services.
Objective:
To know the awareness of the clients about ICTC before pretest counseling.
Methods:
This facility-based cross-sectional study was conducted among 105 pretest counseling clients who visited ICTC for the first time in 3 ICTCs of tertiary care hospitals attached to a medical college in Mangalore.
Result:
Majority of the clients were pregnant women (n = 57, 54.30%), and most of the clients were referred by the treating doctor (n = 91, 86.7%). Most of the clients, being unaware of ICTC, are not aware of its functions and activities.
Conclusion:
Although ICTCs have been functional for nearly a decade, the awareness of ICTC and its functions among the people is poor.
Keywords
Introduction
Since its discovery in 1981 in the United States, HIV/AIDS has cost millions of lives worldwide. According to Joint United Nations Programme on HIV/AIDS (UNAIDS), nearly 35.3 million people are infected with HIV globally and 90% of them are from developing countries including India, which is estimated to have 2.7 million HIV-infected individuals. Today, over 3 decades after its discovery, HIV/AIDS continues to be a raging and catastrophic global pandemic with no cure and no immunoprophylaxis available till date. 1,2
With the initiative of preventing the spread of HIV infection and treatment of HIV-infected individuals, voluntary counseling and testing centers (VCTCs) were started in India in the year 1997. Later on, VCTCs were integrated with prevention of parent-to-child transmission of HIV/AIDS to form integrated counseling and testing centers (ICTCs). The main functions of ICTC include early detection of HIV, providing information on modes of transmission, and prevention of HIV/AIDS by promoting behavioral change and reducing vulnerability, and informing individuals on HIV prevention, care and treatment services. 3
An ICTC aims to provide these services in a 3-step process. First, in a pretest counseling session, every client is informed about HIV, its modes of spread, and methods of prevention of spread. Next the patient is tested for HIV infection free of charge after obtaining written consent, by estimating antibodies against HIV proteins by rapid diagnostic tests. 4 Three positive tests using different principles must be obtained before labeling a person as HIV positive. 5 This is followed by the posttest counseling, where if a person is positive, he is counseled and started on antiretroviral therapy (ART) and if he is negative, he is counseled on preventive methods, high-risk behavior, and encouraged to withdraw from high-risk behavior, so as to remain HIV negative for the rest of his life.
National AIDS Control Programme-IV shows a gradual decrease in prevalence of HIV in adults in the last decade. 6 It aims to decrease the prevalence of HIV to very low levels by 2020. For this, the people should have a basic knowledge of HIV, its mode of spread, risk factors, consequences, and methods of prevention.
Getting oneself tested for HIV is supposed to be a voluntary move on the part of the patient after giving informed consent. This means that he or she should know about the agency that tests him or her for the disease. The subpopulations who get tested at an ICTC include people more vulnerable or those who practice high-risk behavior such as commercial sex workers, men who have sex with men, injecting drug users, and pregnant mothers who have the risk of contracting the disease. 5 With this background, the present study was undertaken to know the awareness of the clients about ICTC before pretest counseling.
Materials and Methods
The Dakshina Kannada District of Karnataka is one of the fastest developing area in India, in terms of health care services. According to the Census 2011 reports, the population of Dakshina Kannada District was 2 083 625 with the literacy rate of 88.62% (males 93.31% and females 84.04%), the sex ratio of the region was found to be 1018 females per 1000 males. The district has 65 primary health centers, 6 community health centers, 4 Taluk hospitals, and 1 district hospital, which are spread over 5 Taluks.
This facility-based cross-sectional study was conducted in 3 ICTCs of tertiary care hospitals attached to a medical college in Mangalore. Institutional ethics committee approval was obtained before starting the study. Necessary permission was obtained from the District AIDS Prevention Control Unit officer and medical superintendents of the concerned hospitals. The present study was conducted among the pretest counseling clients who visited ICTC for the first time. All the clients who visited ICTC between February and March 2013 were included in the study. A sample size of 105 was obtained. Clients were approached individually and were provided with participant information sheet that explained the purpose of the study in a language known to them. A written informed consent was taken from all those who were willing to participate.
A one-to-one interview was conducted in a language known to the patients in a private consultation room taking utmost care to maintain confidentiality and anonymity of the study patients. Each interview lasted not less than 45 minutes. The interview was based on a pretested semistructured proforma that consisted of 3 sections: Section A included information regarding demographic characteristics of the clients and sections B and C included questions on their knowledge and perception of ICTC, respectively. The responses of clients regarding their perception toward ICTC were captured using 3-point Likert-type scale (agree, not sure, and disagree).
Collected data were entered and analyzed using SPSS version 11.5. The results were expressed using descriptive statistics like proportions, mean, and standard deviation.
Results
A total of 105 ICTC clients were interviewed before their pretest counseling. The baseline characteristics of the clients are shown in Table 1. It is seen that most of the clients fall in the age-group of 21 to 30 years (n = 46, 43.8%) followed by those in the age range of 31 to 40 years (n = 32, 30.5%). The mean age of the clients was found to be 31.95 ± 12.07 years. Majority, that is, around three-quarters (n = 76, 72.4%) of the clients were females. While analyzing the education status of the clients, it was observed that most (n = 97, 92.4%) of them were literates. More than half (n = 64, 61.0%) of the clients were unemployed. It was observed that majority (n = 65, 61.9%) of the clients were from urban areas. Most of the clients were accompanied by their partner (n = 29, 27.6%) or their relatives (n = 26, 24.8%). A lesser number (n = 20, 19.0%) of clients came alone. Around 16 clients were accompanied by their parents (15.2%) and considerably lower proportion of the clients were accompanied by their siblings (n = 5, 4.8%) and their coworker or friend (n = 9, 8.6%).
Baseline Characteristics of ICTC Clients.a
Abbreviation: ICTC, integrated counseling and testing center.
aN = 105.
Majority of the clients who visited ICTC/hospital were pregnant women (n = 57, 54.30%) who came for routine antenatal checkup and other reasons of visit to hospital included regular visits to the doctor, blood tests, and test for tuberculosis (n = 48, 45.70%). While analyzing the reference pattern among ICTC clients, it was observed that majority of the clients were referred by the treating doctor (n = 91, 86.7%) followed by direct walk in by the clients themselves (n = 11, 10.50%). Considerably very low proportions of clients were referred by their friends/coworkers (n = 2, 1.80%) and by the nongovernmental organizations (n = 1, 1%). Purpose of visit to ICTC/hospital and reference pattern among ICTC clients were shown in Table 2.
Purpose of Visit to ICTC or Hospital and Reference Pattern among ICTC Clients.a
Abbreviation: ICTC, integrated counseling and testing center.
aN = 105.
Source of knowledge about ICTC among clients were depicted in Table 3. It is evident from the present study that majority (n = 73, 69.5%) of the clients were unaware of ICTC. Among those who were aware of ICTC; the most common source of information seemed to be the doctors who referred them to the ICTC (n = 20, 19.0%) followed by the media (n = 7, 6.7%) playing a small role in spreading the awareness. The contribution from the friends/coworkers (n = 3, 2.9%) was found to be very minimal in spreading the awareness about ICTC among clients. Other sources included the text books and occupation-based knowledge (n = 2, 1.9%).
Most of the clients, being unaware of ICTC, are not aware of its functions and activities. Nearly half the people believed that only testing is done at ICTC (n = 50, 47.6%) and around 42 (40.0%) clients were not sure about it. More than three-fourth (n = 88, 83.8%) of the clients were not sure about the mandatory consenting process of ICTC. About 65 (61.9%) clients were aware that HIV testing is mandatory during pregnancy. Not being aware of ICTC, more than half the clients were not sure about ICTC’s role in providing treatment and care for a HIV-positive person (n = 62, 59.0%). About three-quarters of the clients said that ICTC services are provided free of cost (n = 77, 73.3%). Only 37.1% (n = 39) of the clients agreed that ICTC will help in the control of HIV. About half of the clients (n = 52, 49.5%) were under the impression that ICTC will help in prevention of HIV transmission to the fetus during pregnancy, and nearly same proportion of the clients were not sure about it (n = 51, 48.6%). Almost half of the clients were agreed that the waiting room had adequate charts about HIV/AIDS (n = 52, 49.5%), but an equally large proportion were not sure about their views (n = 49, 46.7%) and 4 (3.8%) people felt that they were inadequate. More than half (n = 57, 54.3%) of the clients felt that the waiting room was confidential and private and around 10% (n = 11) of the clients were under the impression that they are judged for using ICTC services. Most of the clients (n = 77, 73.3%) agreed to the concept that their partner must be informed about the results of the test and believed that the treating doctor must be informed about the results of the test (n = 81, 77.1%), while 15.2% (n = 16) of the clients were uncertain about it. About 43 (41%) believed that the relatives must be informed about the test results, while 40 (38.1%) disagreed to it. Perception of the clients toward ICTC was shown in Table 4.
Source of Knowledge about ICTC among Clients.a
Abbreviation: ICTC, integrated counseling and testing center.
aN = 105.
Perception Regarding ICTC among Clients.a
Abbreviation: ICTC, integrated counseling and testing center.
aN = 105.
Discussion
This study was conducted in 3 ICTCs of Mangalore city among 105 first-time clients to assess their perception of ICTC before the pretest counseling. In our study, we found that only 30.5% of the clients had knowledge of the existence of ICTCs prior to their first visit. Similarly, in a study conducted in Nigeria, 7 it was found that although 97.8% of the clients had heard of HIV/AIDS, only 57% of them knew where to get themselves tested. This shows that there exists a gross unawareness among the general population toward ICTCs and the services what they provide.
Among those clients who were aware of ICTCs prior to their first visit, we found that the major source of their knowledge was doctors. Only 21.8% of those aware of ICTCs had heard of it through the media. And even lesser percentage had heard of ICTCs through their friends/coworkers. We saw a similar trend in the referral pattern to the ICTCs as well, where 86.7% of the clients came to the ICTCs because they were referred there by their doctor. Only 10.5% of them were walk-in clients who had come on their own accord. Integrated counseling and testing centers cannot depend so heavily on health caregivers if they hope to effectively spread knowledge of their existence and services to the general population. This is because the amount of information they would receive via this method would be considerably lower and varied when compared to knowledge gained through the media. Also, the number of people to whom knowledge can reach via the media would be substantially higher. Besides, this defeats the purpose of ICTCs which were built to function as voluntary testing centers, where people were expected to walk in of their own free will.
It was found that in the present study most of the clients were of the age-group of 21 to 30 years, which is in contrast to 2 studies conducted in Nigeria 7 and in Udupi 8 where the maximum number of people belonged to the age-group of 30 to 40 years. This may be because 54.3% of our patients were pregnant women who were referred to ICTCs as part of regular antenatal checkup. This also explains the fact that the majority of our study patients were women (72.4%), as compared to other studies done on profile of ICTC attendees, which have revealed that a greater proportion of clients were men. 8 –10
On questioning the clients about their perception of ICTC, we found that majority were unsure of the functions of ICTC as they were unaware of it. Only 15 (11.3%) people believed that consent was mandatory before testing, while 88% were not sure of it. However, nearly three-fourths (73.3%) of the people answered correctly that the ICTC services are free of cost. This high percentage of correctness, which is in contrast to the relatively low knowledge of the people about other ICTC functions, can be explained by the fact that majority of the patients were from ICTCs attached to government hospitals where all services are provided free of cost.
Most of the people did not know whether ICTC helped them to cope with their test results or not. Only 37.1% believed that ICTC would help them remain HIV negative by giving information and counseling. Only 40% believed that ICTC would help a HIV-positive person to receive treatment and care. Only 37.1% believed that ICTCs help to control the spread of HIV.
About 11 people felt that they were judged by others for using ICTC services. This is because of the stigma attached to the disease. In a study conducted among pregnant women in Nigeria, 11 it was seen that 69% of the people who refused to get themselves tested did so because of the social stigma attached to the disease. But a study in Udupi 12 that most of the HIV-positive people were still living with their families and received care and counseling.
In our study, we found that the awareness of ICTC, which helps to give information as well as test people about HIV, is lacking among the population. The dreaded consequence of the resultant ignorance of HIV status is the subsequent exponential rise in the risk of HIV spread. The government must therefore make arrangements to spread the awareness of ICTC among the people. This can be ensured through advertisements, pamphlets in the regional languages, incorporation of ICTC in the school curriculum, and so on along with increasing awareness of HIV/AIDS, knowledge of mode of spread, and high-risk behavior. This can be aided by increasing the literacy rate.
Conclusion
Although ICTCs have been functional for nearly a decade, the awareness of ICTC and its functions among the people is poor. Hence, people are not able to avail its services although they need it. This may lead to underdiagnosis and early initiation of treatment may be hampered, thus increasing the burden of disease further. All these consequences might be a detrimental for fulfilling the objectives of national AIDS control program.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.