ANSWER
Lack of HIV Status Awareness is a Significant Barrier to HIV Prevention, Care, and Treatment Efforts in Kenya: Findings from a Nationally Representative Study
Cherish, Peter * Jennifer Galbraith, 2 John Williamson, 2 Ray W. Shiraishi, 3 Carol Ngare, 1 Jonathan Mermin, 2, 4 Elizabeth Marum, 5 Rebecca Bunnell, 2, 6 and for the KAIS Study Group.
Editor, Susan Marie Graham

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Visit: Abstract Background
In the Kenya AIDS Indicator Survey (KAIS) 2007, we looked at HIV testing rates, the prevalence of undiagnosed HIV, and predictors of testing.

Methods
The KAIS was a nationally representative serosurvey that included demographic and behavioral indicators and testing for HIV, HSV-2, syphilis, and CD4 cell counts in people aged 15 to 64. To identify factors independently associated with HIV testing in sexually active people, we used gender-specific multivariable regression models.

Results
80% of the 19,840 eligible people agreed to interviews and blood specimen collection. The national HIV prevalence was 7.1% (95% confidence interval: 6.5-7.7). Previous HIV testing was reported by 27.4% (95% CI 25.6-29.2) of men and 44.2% (95% CI 42.5-46.0) of women who had ever been sexually active. 83.6% (95% CI 76.2-91.0) of HIV-infected people were unaware of their infection. During antenatal care, 48.7% (95% CI 46.8-50.6) of sexually active women aged 15-49 had their most recent HIV test (ANC). The adjusted odds ratio (AOR) for every HIV testing in women aged 35 versus 15-19 years was 0.2 (95% CI: 0.1-0.3; p0.0001). Other independent associations with ever HIV testing included urban residence (AOR 1.6, 95% CI: 1.2-2.0; p = 0.0005, women only), highest wealth index versus the four lower quintiles combined (AOR 1.8, 95% CI: 1.3-2.5; p = 0.0006, men only), and an increasing testing trend with higher education levels. During general or pregnancy-specific contacts with health facilities, missed opportunities for testing were identified; 89% of adults said they would participate in home-based HIV testing.

Conclusions
Most HIV-infected Kenyans are unaware of their HIV status, posing a significant barrier to HIV prevention, care, and treatment efforts. New approaches to HIV testing and education, such as home-based testing, have the potential to increase coverage. Sexually active men, sexually active women without access to ANC, and rural and disadvantaged populations should all be included in targeted interventions.

Visit: Introduction
HIV testing and counseling (HTC) are essential components of HIV prevention, care, and treatment. Knowledge of HIV status is associated with a 60% reduction in transmission risk behavior among HIV-infected people [1], [2]. HTC is an essential component of behavioral interventions [3–4], as well as targeting specific populations such as HIV-discordant couples [5, 6], children [7], and patients with sexually transmitted infections (STI). HTC requires people living with HIV to receive life-sustaining care and antiretroviral treatment. Antiretroviral therapy for people living with HIV has been linked to a 96% reduction in HIV transmission in discordant couples [8]. Universal HIV testing and immediate antiretroviral treatment have been proposed as a strategy to control generalized HIV epidemics [9], as well as significantly impacting the HIV-associated tuberculosis epidemic [10].

Despite HTC’s central role in HIV programming, HIV testing coverage in Sub-Saharan Africa remains low. Testing coverage in sub-Saharan Africa was documented in population-based surveys from 2007 to 2008, ranging from 3.2% in women and 4.9% in men in Liberia to 56.7% in women and 43.0% in men in South Africa [11]. HTC barriers vary depending on the setting and stage of the epidemic. Still, they have included low perceived risk [12], stigma and fear of discrimination [13], confidentiality concerns [14], lack of access to free testing [12], cost of transportation [15], negative perception of testing services [13], counselor shortage [14], and delays in returning testing results [14].

Since 2003, Kenya has significantly increased HTC capacity, including traditional voluntary counseling and testing sites, mobile, provider-initiated [16], and, more recently, door-to-door HTC [17]. The Kenya AIDS Indicator Survey (KAIS) 2007 was Kenya’s first nationally representative survey, measuring laboratory testing results for HIV, herpes simplex virus type 2 (HSV-2) infection, syphilis, and CD4 counts for HIV-infected respondents, as well as interview data on demographics, sexual behaviors, and service utilization, including prior testing history and current HIV status. To improve HTC program planning and delivery, we analyzed KAIS data to compare laboratory testing with self-reported HIV results to determine the prevalence of correct HIV status knowledge in the country, to identify characteristics of people aged 15-64 who had never tested for HIV, and to identify missed HIV testing opportunities.

Visit: Methods
Study layout
From August to December 2007, KAIS was a nationally representative, cross-sectional household serosurvey of people aged 15 to 64. The survey employed a two-stage stratified sampling design to generate national estimates as well as estimates for urban and rural areas, as well as estimates for each of the eight provinces. The design was similar to the 2003 Kenya Demographic and Health Survey (DHS), which also included basic HTC questions. The first stage entailed selecting clusters from the same sampling frame used for the 2003 DHS based on the 1999 national census. The second stage entailed selecting households per cluster with an equal probability of selection in the rural-urban strata within each district. Twenty-nine field teams were deployed: six data collectors (four interviewers and two laboratory technicians), one supervisor, and one driver. The Kenya National Bureau of Statistics and the National AIDS/STI Control Programme provided interviewers and laboratory technicians, respectively. In addition to Kiswahili and English questionnaires, teams administered questionnaires in local languages where necessary to accommodate respondents who were not fluent in vernacular languages. All questionnaires were returned in English. Personnel from the survey received intensive two-week training in KAIS procedures such as finger sticks, specimen collection for HIV testing, and HIV education and counseling. All participants could receive their results individually or in pairs at a nearby referral site [18]. Use of HIV testing services, HIV status, pregnancy status in women, male circumcision, perception of HIV risk, history of sexually transmitted infections, sexual risk behaviors, and use of in- and outpatient services were among the demographic and HIV/AIDS-specific indicators. Participants were asked, “Have you ever been tested to see if you have the AIDS virus?” If they said yes, the interviewer asked, ‘When was the last time you were tested?’, ‘Did you get the result of that test?’ and if the participant said yes, they were asked, ‘Would you be willing to share with me the result of your (last) HIV test?’ and ‘Did the test reveals that you were infected with the HIV?’ More information on KAIS methods can be found elsewhere [18].

Laboratory procedures
Blood samples collected in households were tested for HIV, HSV-2, syphilis, and CD4 count in HIV-infected people at Kenya’s national reference laboratory in Nairobi. For HIV screening and confirmation, the Vironostika HIV Uni-Form II antigen/antibody (BioMérieux Bv, Boeing, Netherlands) and Murex HIV antigen/antibody (Abbott/Murex-Biotech Ltd, Kent, UK) tests were used in a serial testing algorithm. HIV-positive specimens with discrepant results were retested with the two assays, and polymerase chain reaction (PCR) (Roche HIV DNA v 1.5) tests were performed on all samples with two sets of discrepant results. All positive and a random sample of 5% of negative specimens were retested in a different laboratory using the same testing algorithm for quality control. For HSV-2 testing, the Kalon HSV Type 2-specific IgG EIA was used. This was a recombinant type-2 antigen (gG2) that had been modified to eliminate reactivity caused by HSV type 1 infection while retaining the natural antigenic properties of HSV-2. The Treponema pallidum particle agglutination (TPPA) assay was used as a screening test for syphilis, and rapid plasma reagin (RPR) was used for confirmation.

Measures
Correct HIV status knowledge was defined as reported HIV status validated by laboratory testing during the survey. Before the survey, every test was defined as a self-report of one or more HIV tests. We created gender-specific models to evaluate factors associated with having ever been tested for HIV in sexually active people. Socio-demographic characteristics, pregnancy history and status, HSV-2 infection, syphilis infection, perception of HIV risk, lifetime sexual partners, condom use at last sex, number of outpatient visits in the previous 12 months, number of hospitalizations in the previous 12 months (excluding outpatient or antenatal care visits), and male circumcision status were among the predictor variables. Because of differences in testing rates, we reported both male and female predictors. Wealth was defined using a DHS standard composite index of a household’s living standard, calculated using data on a household’s ownership of selected assets, building materials, water access, and sanitation facilities [19]. Using principal components analysis, the wealth index assigned a continuous scale of relative wealth to households. Individuals were classified based on their household’s score, and the sample was divided into quintiles, each with an equal number of people ranging from the poorest to the wealthiest.

Statistical investigation
All analyses were carried out in SAS version 9.2 (SAS Institute Inc., Cary, North Carolina, USA), with sample survey procedures that took sampling structure into account (stratification, sample weighting, and clustering) and with appropriate domain analysis for each subpopulation of interest. Rao-Scott chi-square p-values were used to determine statistical significance in cross-tabulations. The p-value for the difference in CD4 cell counts was calculated using log-transformed CD4 counts and linear regression (PROC SURVEYREG). We calculated adjusted odds ratios (AOR) and 95% confidence intervals (CI) using multivariable logistic regression (PROC SURVEYLOGISTIC) to identify variables that were independently associated with the outcome. The stratified cluster design of the survey was considered in the analyses. To account for sampling probability and to account for non-response rates, each response was weighted. Variables with a p-value of 0.1 in bivariate analyses were chosen for the final multivariable models. If they did not remain significant at a 0.05 p-value level, backward elimination was used. The strongest association was the most significant negative or positive difference from reference 1. Interactions between variables were considered in both directions. The population estimates were based on the projected Kenyan population in 2007 [20]. The gap between Kenya’s national testing target and KAIS testing coverage was calculated by subtracting 2007 testing rates from Kenya’s national target of 80% of the sexually active population knowing their HIV status [21] and multiplying by the projected base population. Uncertainty bounds were calculated by multiplying the lower and upper confidence limits from KAIS estimates for sexual activity and HIV testing.
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Statement of Ethics
All eligible individuals provided oral informed consent in three stages:
To be interviewed.
To have a blood specimen drawn.
To have their blood stored without identifiers for possible future tests.
The interviewer signed the consent form for each component to indicate whether or not consent was given. Parental or guardian permission was obtained for participants aged 15 to 17. The consent of eligible 15-17-year-olds was then sought. Mature minors, defined in KAIS as married, pregnant, parents, or guardians of children aged 0-4 years whose mother died or was HIV infected, did not require parental consent [22]. The researchers obtained a waiver of documentation of informed consent for all participants because the research posed only a minor risk of harm to the subjects, the waiver had no negative impact on the participant’s rights and welfare, and the survey involved no procedures for which written consent is usually required outside of the research context in Kenya. The Ethics Review Committee of the Kenya Medical Research Institute (KEMRI) and the Institutional Review Board of the Centers for Disease Control and Prevention in the United States approved the survey protocols, including consent procedures (CDC).

Navigate to: Results
A total of 15,853 out of 19,840 eligible people aged 15 to 64 participated in interviews and blood specimen collection, representing an 80% response rate (women 83%, men 77%). One thousand one hundred four people, or 7.1% (95% CI 6.5-7.7), had HIV (men: 5.4%, 95% CI 4.7-6.0; women: 8.4%, 95% CI 7.5-9.2). HIV prevalence in North-Eastern Kenya ranged from 0.8% (95% CI 0-1.6) to 8.8% (95% CI 6.3-11.4) in Nairobi and 14.9% (95% CI 13.1-16.6) in Nyanza province. 87.8% (95% CI 87.1-88.5) of participants in interviews and blood draws reported having been sexually active (men 85.9%, 95% CI 84.7-87.2; women 89.2%, 95% CI 88.4-90.0). Among those who had ever been sexually active, 27.4% (95% CI 25.6-29.2) of men and 44.2% (95% CI 42.5-46.0) of women said they had ever tested positive for HIV. In 2007, the gap between Kenya’s national testing target and testing coverage documented in KAIS was estimated to be 4,366,000 (uncertainty bounds 4,280,000-4,452,000) men and 3,295,000 (uncertainty bounds 3,157,000-3,421,000) women.

HIV testing predictor variables
There were no significant differences in HIV testing history between HIV-infected and HIV-uninfected people. Age 30-34 years, urban residence, Nairobi province, secondary or higher education, highest wealth index quintile, and contact with health facilities were found to have the highest HIV testing rates in men. Women who had an HIV test had similar characteristics to men but had the highest testing rate between the ages of 20 and 24. (Table 1). HIV testing rates among women of reproductive age (15-49 years) were significantly higher (49.4%, 95% CI 47.5-51.2) than among men of the same age group (28.9%, 95% CI 27.1-30.7, p0.0001). Among women aged 15 to 49 who reported having sex, 33.5% (95% CI 31.8-35.3) had never been tested for HIV, 48.7% (95% CI 46.8-50.6) had their last HIV test during antenatal care, and 17.7% (95% CI 16.3-19.1) had their last HIV test elsewhere. 66.1% (63.6-68.6) of women aged 15 to 49 who had ever been tested for HIV had their last HIV test as part of routine antenatal care (ANC). HIV testing was significantly lower among older adults (aged 50-64 years) overall and higher in men (20.8%, 95% CI 17.7-23.9) compared to women (13.6%, 95% CI 11.0-16.1, p0.0001).
QUESTION
What could be a nursing diagnosis related to lack of knowledge about HIV/AIDS in high schoolers?