|Year : 2014 | Volume
| Issue : 4 | Page : 161-168
Human immunodeficiency virus screening in rural communities of Rivers State, Nigeria: Challenges and potential solutions
Charles I Tobin-West1, Victor N Onyekwere2
1 Department of Preventive and Social Medicine, College of Health Sciences, University of Port Harcourt, Port Harcourt, Nigeria
2 Department of Preventive and Social Medicine, College of Health Technology, Port Harcourt, Nigeria
|Date of Web Publication||7-Oct-2014|
Charles I Tobin-West
Department of Preventive and Social Medicine, Rivers State College of Health Technology, University of Port Harcourt, Port Harcourt
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Human immunodeficiency virus (HIV) testing and counseling has remained significantly low in rural communities of Nigeria despite the huge benefits of early case detection and treatment. This study aims at evolving strategies based on the health-seeking attitudes of rural people in order to improve their HIV testing access.
Materials and Methods: A cross-sectional study was carried out between May and June 2011 among persons of reproductive ages, that is, 15 years and above for men and 15-49 years for women; normally resident in rural communities of Rivers State, Nigeria, selected using a multistage sampling technique.
Results: A total of 267 (42.0%) males and 368 (57.9%) females were interviewed. Most of the respondents (619, 97.5%) had heard about HIV, and 498 (78.4%) were aware of its transmission by sexual route. Condom use was low and non-use with a nonmarital partner 12 months preceding the survey was 33.8% (191). Only 242 (38.1%) had ever tested for HIV: 90 (37.2%) men and 152 (62.8%) women (χ2 = 15.14, degree of freedom (df) =1, P = 0.000), while only 33 (13.6%) had tested for HIV based on sexual risk perceptions. The commonest reasons for HIV testing were pregnancy, premarriages, and test for concordance. Reasons for not testing were lack of perception of HIV risk, fear of stigmatization, and discrimination from positive test result.
Conclusion: This study highlights the persistence of low HIV testing culture in rural settings in Nigeria and underscores the need that HIV programs should look beyond the healthcare settings and involve the communities, using home and community-based testing approaches in order to expand HIV testing access.
| Abstract in French|| |
Contexte: Immunodιfience humaine (VIH) tests et de counselling est restι trθs faible dans les communautιs rurales du Nigιria en dιpit des ιnormes avantages de dιpistage prιcoce des cas et le traitement. Cette ιtude vise ΰ l'ιvolution des stratιgies fondιes sur des attitudes de health-seeking des populations rurales afin d'amιliorer leur accθs de dιpistage du VIH.
Matιriel et mιthodes: Une ιtude transversaux a ιtι rιalisιe entre mai et juin 2011 chez les personnes d'βge reproductif, c'est-ΰ-dire 15 ans et plus pour les hommes et 15-49 ans pour les femmes; normalement rιsident dans les collectivitιs rurales de l'ιtat de Rivers, Nigeria, sιlectionnιs ΰ l'aide d'une technique d'ιchantillonnage multimodes.
Rιsultats: Les hommes un total de 267 (42,0 %) et 368 (57,9 %) les femmes ont ιtι interrogιes. La plupart des rιpondants (619, 97,5 %) avait entendu sur le VIH et 498 (78,4 %) ιtaient au courant de sa transmission par voie sexuelle. L'utilisation du prιservatif ιtait faible et non-usage avec un partenaire hors des 12 derniers mois prιcιdant l'enquκte ιtait 33,8 % (191). Seule 242 (38,1 %) avait jamais testι pour le VIH : 90 hommes (37,2 %) et 152 (62,8 %) femmes (X 2 = 15.14, degrι de libertι (df) = 1, P = 0.000), tandis que seulement 33 (13,6 %) avait testι pour le VIH fondιe sur la perception des risques sexuels. Les motifs plus courantes pour le dιpistage du VIH ont ιtι grossesse, premarriages et test de concordance. Raisons pour ne pas tester ιtaient le manque de perception du risque de VIH, la peur de la stigmatisation et la discrimination de rιsultat positif.
Conclusion: Cette ιtude met en ιvidence la persistance du faible dιpistage de culture en milieu rural au Nigeria et souligne la nιcessitι que les programmes VIH devraient regarder au-delΰ des ιtablissements de soins et faire participer les communautιs, ΰ l'aide ΰ domicile et tester des approches rattachιes ΰ la communautι afin d'ιlargir l'accθs de dιpistage du VIH.
Mots-clιs: Le dιpistage du VIH, Nigeria, l'ιtat de Rivers, les communautιs rurales
Keywords: HIV testing, Nigeria, Rivers State, rural communities
|How to cite this article:|
Tobin-West CI, Onyekwere VN. Human immunodeficiency virus screening in rural communities of Rivers State, Nigeria: Challenges and potential solutions. Ann Afr Med 2014;13:161-8
|How to cite this URL:|
Tobin-West CI, Onyekwere VN. Human immunodeficiency virus screening in rural communities of Rivers State, Nigeria: Challenges and potential solutions. Ann Afr Med [serial online] 2014 [cited 2020 Aug 11];13:161-8. Available from: http://www.annalsafrmed.org/text.asp?2014/13/4/161/142281
| Introduction|| |
Nigeria is one of the countries in sub-Saharan Africa affected by the Human immunodeficiency virus (HIV) pandemic. There were approximately 220,000 acquired immunodeficiency syndrome (AIDS) related deaths in Nigeria in 2009,  and Nigeria's life expectancy declined significantly from 54 years for women and 53 years for men to 48 years for women and 46 years for men between 1991 and 2009. , Rivers State is one of the states of Nigeria with a HIV and AIDS seroprevalence rate of 6.0% and is one of the few states in the country with a seroprevalence rate higher than the national median prevalence of 4.1%. 
In Nigeria, heterosexual transmission of HIV accounts for 80-95% of infections,  while issues such as lack of information about sexual health and HIV, low levels of condom use, and high levels of sexually transmitted infections (STIs) contribute to the spread of the disease.  In addition, low perception of HIV risk among those in sexual relationships who do not have adequate knowledge of the sexual history and HIV status of their partners is a major source of concern. ,, Such people do not often see the need to take steps to protect themselves from HIV infection or know their HIV status even when it is obvious that they engage in high risk sexual behaviors.  A study by Prata, et al.,  in Mozambique showed low uptake of HIV counseling and testing (HCT) among those who felt they had a low chance of HIV infection when compared with those who felt they had a high chance of contracting the infection.
Nigeria developed a National Strategic Framework (NSF) in line with the global target for ensuring universal access to HCT as a strategy for reducing the HIV and AIDS burden.  The target was to reach 80% of sexually active adults and 80% of most at-risk populations with HCT services by 2015.  This is because HIV testing has been recognized as significant step in efforts to minimize the spread of the epidemic and ensure universal access to HIV prevention, treatment, care and support.  However, because of the slow progress in achieving large scale behavior change, it became necessary to combine behavioral change strategies with efforts to improve early case finding through the expansion of HCT services. If properly implemented, it will go a long way in ensuring a sustained reduction in the HIV and AIDS prevalence in the country.
Some challenges; however, like linking HIV infection with socially unacceptable behaviors such as promiscuity and sex work promote stigma and discrimination against HIV positive persons. This further prevents people from knowing or disclosing their HIV status, or even seeking treatment after testing positive to HIV. ,,, Therefore, encouraging people to test voluntarily before they develop symptoms of the infection remains a major challenge. This is particularly important in a country like Nigeria where uptake of HCT is only 10% and as low as 8% in some regions, especially in rural areas.  Poor utilization of HCT services results in delayed diagnosis which not only poses a higher cumulative risk of HIV transmission to others, ,, but also leads to increased mortality and morbidity. ,, Late presentation accounts for as many as 77% of AIDS-related death globally  and has been implicated as a major contributor to HIV and AIDS mortality in sub-Saharan Africa, especially in persons with steady partnerships who consider themselves as low risk for the infection.  On the contrary, early case detection and initiation of therapy has been associated with likely reduction in transmission, morbidity, and incidence of tuberculosis. , It has also been linked with improved life expectancy. 
The importance of early case findings through HCT in reducing AIDS mortality and transmission rates therefore, cannot be overemphasized. This is because limiting access to testing also limits timely access to care and is a potential source of harm to both HIV positive and HIV negative individuals. It is thus important to examine the issues surrounding HIV screening in rural communities and propose strategies in line with the behavioral pattern and health-seeking attitudes of the people that will improve access and acceptability of HIV testing.
| Materials and Methods|| |
The study was carried out in Rivers State, one of the 36 states in Nigeria, located in its oil rich Niger Delta region. The state has a population of about 5.6 million and is made up of as many as 20 ethnolinguistic groups. Administratively, it has three senatorial districts and 23 local government areas (LGAs). Each senatorial district is made up of seven to eight LGAs. Approximately, three quarters of the population reside in rural areas. The predominant occupations of the people are fishing, farming, and petty trading.
There has been a rising trend of HIV and AIDS and other sexually transmitted diseases within the state. This has been attributed to the high incidence of transactional sex and risky sexual behaviors as a result of the influx of highly mobile, young, and sexually active populations into the oil rich region.  This setting has serious implications for the spread of HIV/AIDS, since HIV transmission has been shown to be higher in highly mobile populations. ,,, Currently, the state has a total of 183 HCT centers located within its health facilities.
The study was carried out in the rural communities of the state among men who were 15 years and above and women who were between 15 and 49 years that are normally resident in these communities. Visitors and those who had lived less than 1 year in the communities were excluded.
Design and sampling
The study was a descriptive, cross-sectional, household-based study carried out between May and June 2011. A minimum sample size of 621 was determined for the study, using the formula for descriptive studies;  n = Z 2 pq/d 2 , where n = minimum sample size, Z = normal standard deviate, 1.96 at 95% confidence level, P = prevalence of HIV screening in Nigeria of 10%,  q = 1 – p, d = error margin of 3.5%, with adjustments for design effect (DEFT) =2, and nonresponse rate of 10%. A pretested, semi structured, interviewer-administered questionnaire was used to collect information from respondents. The questionnaire was made up of the following sections: Section one - contained information on the demographic profile of respondents; section two - knowledge of HIV; section three - sexual risk behavior; and section four - HIV screening status and factors influencing screening.
Selection of respondents was by a multistage sampling method. The first stage was the random section of one LGA from each of the three senatorial districts that make up the state by a simple random method. The second stage was the selection of communities from each of the three selected LGAs. A list containing all the major communities and their population in each of the LGAs was obtained from the office of the National Population Commission (NPC) situated in the LGA headquarters. Using the list as a frame, one community was randomly chosen from each of the three LGAs by a simple random method. The final stage was the selection of houses and households from the communities. This was done by identifying a central location in each community and spinning a pen on the floor to determine the direction of the first house to administer the questionnaire. In each house, all the households were identified and all eligible targets that consented to participate in the study were interviewed. After the first household, the next household interviewed was the nearest consecutive household. The process was continued until the assigned sample size was achieved. A total of 200-250 persons were interviewed in each community based on population of the community. The interviews were conducted in English and Pidgin English that is widely spoken in the rural areas of the state. However, local dialects were used where necessary. They were conducted by volunteers earlier trained on the research protocol, questionnaire administration, and the ethical issues involved with the study.
All generated data were collated, verified for accuracy, and analyzed using Epi Info ver. 6.04d statistical package. Frequencies and basic descriptive statistics were calculated, including cross tabulations to determine potential relationships between key variables. The Chi-squared test was used to compare observed differences in proportions. A P < 0.05 was considered significant.
Ethical clearance was obtained from the Research and Ethics Committee of the University of Port Harcourt Teaching Hospital. Permission to conduct the study was obtained from the local government health authorities and community leaders. Verbal informed consent was obtained from each participant after thorough explanation of the aim and objectives of the study. They were assured of confidentiality of their views and opinions, and informed that they were free to decline from participating at any stage of the interview without any sanctions.
| Results|| |
Demographic profile of respondents
The sociodemographic profile in [Table 1] reveals that 267 (42.0%) males and 368 (58.0%) females participated in the study. Persons in the age bracket 15-24 years constituted majority of the respondents (209, 32.9%). A total of 311 (49.0%) were married and 258 (40.0%) were single. Most of the respondents had formal education as opposed to only 75 (11.8%) who had no formal education.
Knowledge of HIV and its modes of transmission
Nearly all the respondents (619, 97.5%) were aware of the HIV infection and its modes of transmission, but only 299 (47.1%) knew that an infected pregnant women could transmit the virus to her unborn baby. Similarly, most of the respondents correctly identified abstinence as well as use of condoms and faithfulness to an uninfected partner as ways of protection from the infection [Table 2].
Sexual Risk Behavior among Respondents
Most of the respondents were sexually active 565 (89.0%), with the women folks more exposed than men: 223 (39.5%) versus 342 (60.5%) (χ2 = 24, degrees of freedom (df) =1, P = 0.000). However, sexual risk exposures such as nonmarital sex without a condom in the last 12 months preceding the survey were commoner among the men 106 (55.5%) than the women 85 (44.5%) (χ2 = 2.26, df = 1, P = 0.132). Only 33 (13.6%) of those who had tested for HIV did so based on their perception of high sexual risk behaviors. All those who reported STI symptoms such as sore or rash on the penis, vulva, or vagina in the previous 1 year were 72 (11.3%). They consisted of 39 (54.2%) men and 33 (45.8%) women (χ2 = 0.50, df = 1, P = 0.478). However, only 21 (8.7%) of these tested for HIV despite evidence of their STIs [Table 3].
HIV screening and reasons for and against screening
Overall, only 242 (38.1%) of the respondents had ever been screened for HIV. They were 82 (33.9%) males and 160 (66.1%) females (χ2 = 22.61, df = 1, P = 0.000). The commonest reason for screening was prenatal screening among women during pregnancy. Others were partner screening to determine HIV concordance among couples (39, 16.3%), voluntary screening based on individuals' knowledge about HIV infection (27, 11.2%), and medical illness or surgery (22, 9.1%). In contrast, reasons for not screening for HIV among both sexes were not significantly different. They included the low perception for HIV risk (144, 36.6%), fear of stigmatization if test result was positive (102, 26.0%), fear of death from HIV if test was positive (71, 18.1%), fear of discrimination (62, 15.8%), and lack of trust that health workers would maintain confidentiality of the HIV test result (143.6%) (χ2 = 6.63, df = 10, P = 0.676) [Table 4].
| Discussion|| |
The study revealed high level of awareness about HIV and its modes of transmission among the respondents. This was however expected in view of the massive publicity about the HIV epidemic in the past 3 decades in many parts of sub-Saharan Africa. Nevertheless, the rate of HIV screening was low among the respondents and sexual risk behaviors still rampant. For instance, nearly a third of the respondents had unprotected sexual exposures in the past 1 year preceding the survey, yet only 13.6% of them had tested for HIV on account of high risk sexual behaviors. Similarly, only 8.7% of those with STI symptoms were ever tested for HIV. This scenario poses a potential threat in a country like Nigeria or elsewhere in sub-Saharan Africa, where over 80% of HIV infections are transmitted by heterosexual means,  and about 3.5 million people are already living with virus and contributing over 300,000 new infections annually. 
Among those ever screened for HIV, compelling reasons like prenatal screening during pregnancy and premarriage screening were the major motivations for screening. Prenatal screening was particularly common. This corroborates the findings of Ekanem and Gbadegesin  that Nigerian women would be more willing to be screened for HIV if the knowledge of their HIV status would aid in preventing HIV transmission to their babies. Similar reports have also been documented in other African countries among prenatal care attendees, where HIV testing increased with the introduction of provider initiated testing and counseling (PITC). ,
The major reason for declining a HIV test was low perception of HIV risk, with some respondents claiming they were certain they were not infected. Others were fear of stigmatization from HIV positive test result. These reasons probably stemmed out of lopsided knowledge about HIV infection and its impact, or that people are simply still deeply rooted in the flawed denial of their sexual risk behaviors. Such behaviors could prevent individuals from taking necessary steps in protecting themselves from getting infected or getting to know their HIV serostatus even when they engage in high risk behaviors. , This thus support the notion suggested in some studies that low risk perception fuels the HIV epidemic. ,, This could also explain the late presentation of cases for treatment, care, and support commonly seen in Nigeria, consequently resulting in poor clinical outcomes for those infected with the virus. ,,,,, Similar finding was reported by Bwambale, et al., in a study in rural western Uganda where low perception of sexual risk was a barrier for HIV screening.  Also, an opportunity would have been missed or delayed for behavioral modifications, because studies have demonstrated that those who knew their HIV status were more likely to take preventive measures like consistent condom use or modified their sexual risk behaviors. ,,
Hitherto, client-initiated voluntary counseling and testing had been the primary model for HIV testing in Nigeria and in many low and middle income countries. Increasingly though, provider-initiated approaches in clinical settings are being promoted.  However, because substantial proportion of the population in Nigeria depend on the informal sector healthcare providers such as proprietary patent medicine vendors for healthcare services. This is because they perceive them to be friendlier, easily approachable, and show more empathy than orthodox healthcare practitioners. ,, For this reason, significant proportion of the HIV vulnerable population in rural settings is constantly being missed with valuable provider initiated testing services.
This peculiarity in healthcare seeking behaviors which limit contact with the formal health system highlights issues that are critical to the mix of HIV testing approaches using the home and community-based HIV testing and the informal sector, non-health facility-based HIV testing in order to expand access to early diagnosis and care of HIV patients. Home-based counseling and testing (HBCT) is a potential strategy for early identification of patients prior to the severe depletion of their CD4 T cells. This strategy is necessary to link up at-risk populations such as adolescents, men, and the elderly who usually have poor health seeking behaviors with treatment programs, , thereby ensuring better health outcomes. It is also important for early identification of discordant couples and linking them up with treatment, care, and support to prevent further viral spread.  It can be implemented using the opt-out strategy and standardized guidelines, while addressing associated ethical concerns and human right issues. Earlier studies on home-based testing have proven to be acceptable and successful in rural settings. ,
The primary goal of HIV and AIDS prevention and control is to reduce new infections, morbidity, and mortality through early case detection and initiation of treatment. The hub of health services delivery in Rivers State has been through the formal health sector and its network of facilities. However, only a fraction of vulnerable people needing health services are reached by the few trained personnel available in many developing countries. The nonformal sector seems to have the greatest potential in improving access to healthcare services, including HIV prevention and control. This is because this sector is generally more accessible geographically, socially, and involves less time wasting. ,,
The study was based on self-reports and thus subject to some measure of response bias. The stigma associated with HIV infection might cause some respondents to underreport or even over report HIV screening issues. However, several measures that improve the quality of self-reports such as dwelling on recent events, establishing a good rapport with respondents, simplifying questions, permitting respondents to answer at their own pace,  and in their language if necessary were applied to improve the quality of the data.
| Conclusion|| |
This study therefore highlights the persistence of lopsided knowledge about HIV and low testing culture in rural settings. It also underscores the need that HIV programs should look beyond the healthcare settings and involve the communities using home and community-based testing approaches in order to expand HIV testing and counseling access. In addition, it highlights a critical need for further studies on the suitability of using informal sector, community, or other non-health facility-based providers like proprietary medicine vendors who are perceived to be friendlier and more receptive to enhance the current PITC scale-up HIV testing in resource poor settings, in line with the philosophy of primary healthcare and the utilization of available local resources.
| Acknowledgement|| |
Our gratitude goes to the various community leaders who made it possible to carry out the study in their domains and the various community guides and translators/interpreters who assisted the data collection teams.
| References|| |
|1.||UNAIDS.org. Report on the global AIDS epidemic. Available from: target="_blank" href="http://www".unaids.org/globalreport/Global_report.html"[Last cited on 2013 Jan 7]. |
|2.||World Health Organization. Country Health Profile of Nigeria. Available from: target="_blank" href=".afro.who.int/en/nigeria/country-health-profile.html" [Last cited on 2013 Jan 7]. |
|3.||Central Intelligence Agency. World Fact book (2010) Nigeria. Available from: https://www.cia.gov/library/publications/the-world-factbook/geos/ni.html [Last cited on 2013 Jan 7]. |
|4.||National Agency for the Control of HIV/AIDS [NACA]. Global AIDS Response: Nigeria Country Report 2012. Available from: target="_blank" href="unaids.org/en/dataanalysis/knowyourresponse/countryprogressreports/2012countries/Nigeria%202012%20GARPR%20Report%20Revised.pdf[Last cited on 2013 Jan 7]. |
|5.||Nasidi A, Harry TO. The epidemiology of HIV in Nigeria. In: Adeyi O, Kanki PJ, Odutolu O, Idoko JA, editors. AIDS in Nigeria: A Nation on the Threshold. Cambridge, MA: Harvard Center for Population and Development Studies; 2006. p. 37-130. |
|6.||National Agency for the Control of HIV/AIDS. Brief on HIV response in Nigeria. Available from: http://www.naca.gov.ng/content/view/421/lang.en/Last cited on 2012 Nov 12]. |
|7.||Global HIV prevention working group. Behavior change and HIV prevention: Considerations for the 21 st Century. Available from: target="_blank" href="http://www.globalhivprevention.org/pdfs/PWG_behavior%20report_FINAL.pdf"[Last cited on 2012 Nov 12]. |
|8.||United Nations Development Programme. Human Development Report International cooperation at a crossroads: Aid, trade and security in an unequal world. Available from: target="_blank" href="http://www.hdr.undp.org/en/media/HDR05_complete.pdf"[Last cited on 2012 Dec 19]. |
|9.||Delpierre C, Dray-Spira R, Cuzin L, Machou B, Massip P, Lang T, et al. VESPA Study Group. Correlates of late HIV presentation: Implications for testing policy. Int J STD AIDS 2007;18:312-7. |
|10.||Prata N, Morris L, Mazive E, Vahidnia F, Stehr M. Relationship between HIV risk perception and condom use: Evidence from a population-based survey in Mozambique. Int Fam Plan Perspect 2006;32:192-200. |
|11.||Obermeyer CM, Osborn M. The utilization of testing and counseling for HIV: A review of the social and behavioral evidence. Am J Public Health 2007;97:1762-74. |
|12.||National Agency for the Control of HIV/AIDS. Nigeria National Strategic Framework 2010-2015. Abuja, Nigeria: NACA; 2009. p. 1-54. |
|13.||Averting HIV and AIDS. HIV/AIDS stigma and discrimination. Available from: target="_blank" href="http://www.avert.org/hiv-aids-stigma.htm"[Last cited on 2012 Jun 12]. |
|14.||Phillips KA, Coates TJ, Catania JA. Predictors of follow-through on plans to be tested for HIV. Am J Prev Med 1997;13:193-8. |
|15.||Ma W, Detels R, Feng Y, Wu Z, Shen L, Li Y, et al. Acceptance of and barriers to voluntary HIV counseling and testing among adults in Guizhou province, China. AIDS 2007;21:129-35. |
|16.||Ostermann J, Reddy EA, Shorter MM, Muiruri C, Mtalo A, Itemba DK, et al. Who tests, who doesn′t, and why? Uptake of mobile HIV counseling and testing in the Kilimanjaro region of Tanzania. PLoS One 2011;31;6:e16488. |
|17.||Federal Ministry of Health. National HIV/AIDS and Reproductive Health Survey. Abuja, Nigeria: FMOH; 2007. p. 25-33. |
|18.||Sterling TR, Chaisson RE, Keruly J, Moore RD. Improved outcomes with earlier initiation of highly active antiretroviral therapy among human immunodeficiency virus infected patients who achieve durable virologic suppression: Longer follow-up of an observational cohort study. J Infect Dis 2003;188:1659-65. |
|19.||Gray RH, Wawer MJ, Brookmeyer R, Sewankambo NK, Serwadda D, Wabwire-Mangen F, et al. Rakai Project Team. Probability of HIV-1 transmission per coital act in monogamous heterosexual HIV discordant couples in Rakai, Uganda. Lancet 2001;357:1149-53. |
|20.||Vernazza PL, Troiani L, Flepp MJ, Cone RW, Schock J, Roth F, et al. Potent antiretroviral treatment of HIV-infection results in suppression of the seminal shedding of HIV. The Swiss HIV Cohort Study. AIDS 2000;14:117-21. |
|21.||Adler A, Mounier-Jack S, Coker RJ. Late diagnosis of HIV in Europe: Definitional and public health challenges. AIDS Care 2009;21:284-93. |
|22.||Sanders GD, Bayoumi AM, Sundaram V, Bilir SP, Neukermans CP, Rydzak CE, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med 2005;352:570-85. |
|23.||Girardi E, Sabin CA, Monforte AD. Late diagnosis of HIV infection: Epidemiological features, consequences and strategies to encourage earlier testing. J Acquir Immune Defic Syndr 2007;46:S3-8. |
|24.||Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011;365:493-505. |
|25.||Ford N, Kranzer K, Hilderbrand K, Jouquet G, Goemaere E, Vlahakis N, et al. Early initiation of antiretroviral therapy and associated reduction in mortality, morbidity and defaulting in a nurse-managed, community cohort in Lesotho. AIDS 2010;24:2645-50. |
|26.||Mills EJ, Bakanda C, Birungi J, Chan K, Ford N, Cooper CL, et al. Life expectancy of persons receiving combination antiretroviral therapy in low-income countries: A cohort analysis from Uganda. Ann Intern Med 2011;155:209-16. |
|27.||Tobin-West CI, Okeh CM. Rivers State of Nigeria HIV/AIDS strategic plan (2005-2009): An evaluation of accomplishments and gaps. Port Harcourt Med J 2012;6:281-91. |
|28.||International Organization for Migration/UNAIDS. HIV and mobile workers: A review of risks and programmes among truckers in West Africa. Available from: target="_blank" href=http://www.siteresources.worldbank.org/INTTSR/Resources/4626131135099994537/MIL6010070.pdf"[Last cited on 2012 Jun 12]. |
|29.||Dworkin SL, Ehrhardt AA. Going beyond "ABC" to include "GEM": Critical reflections on progress in the HIV/AIDS epidemic. Am J Public Health 2007;97:13-8. |
|30.||Coffee M, Lurie MN, Garnett GP. Modelling the impact of migration on the HIV epidemic in South Africa. AIDS 2007;21:343-50. |
|31.||Popoline.org. Thailand: Family Health International, Asia and Pacific Department; Protecting people on the move: Applying lessons learned in Asia to improve HIV/AIDS interventions for mobile people. Available from: target="_blank" href=http://www. [Last cited on 2012 Nov 3]. |
|32.||Campbell MJ, Machin D. Medical Statistics. A common sense approach. 2 nd ed. London: John Willey and Sons Ltd; 1996. |
|33.||Ekanem EE, Gbadegesin A. Voluntary counseling and testing for human immunodeficiency virus: A study on acceptability by Nigerian women attending antenatal clinics. Afr J Reprod Health 2004;8:91-100. |
|34.||Chandisarewa W, Stranix-Chibanda L, Chirapa E, Miller A, Simoyi M, Mahomva A, et al. Routine offer of antenatal HIV testing ("opt-out" approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe. Bull World Health Organ 2007;85:843-50. |
|35.||Baggaley R, Hensen B, Ajose O, Grabbe KL, Wong VJ, Schilsky A, et al. From caution to urgency: The evolution of HIV testing and counseling in Africa. Bull World Health Organ 2012;90:652-58B. |
|36.||Wanyenze RK, Kamya MR, Fatch R, Mayanja-Kizza H, Baveewo S, Sawires S, et al. Missed opportunities for HIV testing and late-stage diagnosis among HIV infected patients in Uganda. PLoS ONE 2011;6:e21794. |
|37.||Bwambale FM, Ssali SN, Byaruhanga S, Kalyango JN, Karamagi CA. Voluntary HIV counseling and testing among men in rural western Uganda: Implications for HIV prevention. BMC Public Health 2008;8:263. |
|38.||Herndon B, Asch SM, Kilbourne AM, Wang M, Lee M, Wenzel SL, et al. Prevalence and predictors of HIV testing among a probability sample of homeless women in Los Angeles County. Public Health Rep 2003;118:261-9. |
|39.||Fonner VA, Denison J, Kennedy CE, O′Reilly K, Sweat M. Voluntary counseling and testing for changing HIV related risk behavior in developing countries. Cochrane Database Syst Rev 2012;9:CD001224. |
|40.||Glanz K, Rimer BK, Lewis FM. Health Behavior and Health Education: Theory, Research and Practice. San Francisco: John Wiley and Son Ltd; 2002. |
|41.||Erhun WO, Adebayo A. Students′ management of perceived malaria in a Nigerian University. J Soc Adm Pharm 2002;19:151-60. |
|42.||Brugha R, Zwi A. Improving the quality of private sector delivering of public health services: Challenges and strategies. Health Policy Plan 2002;13:107-20. |
|43.||Stenson B, Syhakhang L, Eriksson B, Tomson G. Real world pharmacy: Assessing the quality of private pharmacy in Lao People′s Demographic Republic. Soc Sci Med 2001;52:393-404. |
|44.||Bakanda C, Birungi J, Mwesigwa R, Nachega JB, Chan K, Palmer A, et al. Survival of HIV-infected adolescents on antiretroviral therapy in Uganda: Findings from a nationally representative cohort in Uganda. PLoS One 2011;6:e19261. |
|45.||Bakanda C, Birungi J, Mwesigwa R, Ford N, Cooper CL, Au-Yeung C, et al. Association of aging and survival in a large HIV-infected cohort on antiretroviral therapy. AIDS 2011;25:701-5. |
|46.||Mills EJ, Ford N. Home-Based HIV counseling and testing as a gateway to earlier initiation of antiretroviral therapy. Clin Infect Dis 2012;54:282-4. |
|47.||Naik R, Tabana H, Doherty T, Zembe W, Jackson D. Client characteristics and acceptability of a home-based HIV counseling and testing intervention in rural South Africa. BMC Public Health 2012;12:824. |
|48.||Kyaddondo D, Wanyenze RK, Kinsman J, Hardon A. Home-based HIV counseling and testing: Client experiences and perceptions in Eastern Uganda. BMC Public Health 2012;12:966. |
|49.||Gelberg L, Siecke N. Accuracy of homeless adults′ self reports. Med Care 1997;35:287-90. |
[Table 1], [Table 2], [Table 3], [Table 4]