Abstract
Nnewi is a rural Nigerian town with a human immunodeficiency virus (HIV) counseling and testing center which tests about 120 clients/d. The objective of this study is to determine the factors predicting positive HIV status at Nnewi. Review of records was done with age, gender, marital status, and occupation as variables. Logistic regression analysis was used to identify factors linked to a positive HIV test. Overall HIV prevalence was 31.14%. Drivers and married clients had a high risk of being HIV+ (odds ratio [OR], 3.59; 95% confidence interval [CI], 2.17-5.96 and OR, 2.78; 95% CI, 2.42-3.19). Housewives were 2 times more likely to be positive (OR, 2.11; 95% CI, 1.35-3.29). After adjustment, females had 22% higher risk (OR, 1.22; 95% CI, 1.03-1.45) with the highest chance found in married females (OR, 6.70; 95% CI, 4.45-10.09). The study succeeded in panning out an unexpected risk group: married women. Drivers have been known to be a risk group. Preventive methods must be tailored to and acceptable by each risk group.
Introduction
The United States Government–supported human immunodeficiency virus (HIV) treatment and care program, through the Presidential Emergency Funds for AIDS Relief (PEPFAR), started in April 2005 through the Institute of Human Virology, Nigeria (IHVN) in an HIV care center in the small town of Nnewi, located in Anambra state. The 2005 national sentinel survey revealed the prevalence of HIV is 4.2% in Anambra State. 1 The basic occupation among Nnewi citizens is trading but agriculture and civil service are the common professions. The town is located near Onitsha, the commercial nerve center of south eastern Nigeria. Rural Nnewi, affected by Nigerian civil war in 1967 to 1970, has grown to have a large number of small indigenous industries, automotive spare parts in particular, and traders come from far away places to acquire spare parts in Nnewi and the neighboring Town, Onitsha.
In Nnewi, the “Heart to Heart” center, that is, HIV counseling and testing (HCT) center, started its operations as a small unit in the year 2002. Services were scaled up with PEPFAR support. This support brought an increase in influx of patients. High emphasis was on strict compliance to National Testing Guidelines and Standard Operating Procedures with frequent assessments for quality assurance and quality control for HCT.
In this study, data on clients visiting the HCT center were collected for sequential visits, from the HCT log books.
The aim of the study is to find out what sociodemographic factors predict the HIV status for the clients seen at “Heart to Heart,” Nnewi. This information will be used to design new and to improve on current HIV preventions strategies.
Methods
Retrospective review of HCT records over a period of 5 months, December 2005 to April 2006, was done. The majority of the clients were walk-ins, but referrals from various departments in the adjacent hospital or other health facilities were not excluded from the study. All clients were group-counseled daily, tested with 2 separate kits for rapid test kits: Determine (Abbott Laboratories, Tokyo, Japan) and Cappillus HIV-1/HIV-2 (Trinity Biotech, Jamestown, New York) following the national testing algorithm. All screening tests were carried out by laboratory technicians. For discordant results, a third test, Genie (Genie II HIV-1/HIV-2, Bio-Rad, Marnes la Coquette, France), was used as a “tie breaker.” Clients tested were postcounseled individually according to their results on the same day. Data were stripped of all identifiers to maintain client confidentiality.
Independent variables included age, gender, marital status, and occupation. Age was collected as a continuous variable and grouped into 4 different categories from 15 years with intervals of 10 years. All occupations accounting for less than 2% of the cohort were grouped as “others.” This included farmers, doctors, missionaries, musicians, restaurant entrepreneurs, and soldiers. The outcome measure was the HIV status. Study population was 4111. Sixty-one (0.01%) missing values were excluded from the analysis. Analysis consisted of descriptive data of frequency tables (percentages), means with standard deviation, bivariate and multivariate logistic regression analysis, test of interaction, and log likelihood ratios. A P value of less than .05 was considered significant. All statistical analyses were done with STATA 8.2 (Statacorp, College Station, Texas, 2005).
Results
The mean age was 31 years (SD ±8) ranging between 15 and 55 years. A t test showed a difference between the mean age for clients in the 2 outcome categories (P < .001). About three-fifths of this population was female, 47% were within the age range of 25 to 34 years, 50% in sales-related vocation and 20% were students. Ratio of married to single population was approximately 1:1.
Overall prevalence of infection was 31.14% in this cohort. Prevalence among married clients was 43% and 60% among truck drivers (Table 1). Univariate analysis showed that drivers had the highest chance of testing HIV positive (OR, 3.59; 95% CI, 2.17-5.96), this association was maintained in multivariate analysis (OR, 4.15; 95% CI, 2.44-7.03; Table 2). Married clients had 2.8 times higher chance of testing positive compared with singles (OR, 2.78; 95% CI, 2.42-3.19). After adjusting for age and marital status, females had 22% higher risk of being HIV positive compared with males. The risk of HIV infection increased significantly with age. This trend was maintained in the multivariate analysis. Housewives were found to be twice more likely to be positive (OR, 2.11; 95% CI, 1.35-3.29) while students were less likely to test positive (OR, 0.47; 95% CI, 0.32-0.70), compared with other professional categories (Table 2).
Distribution of HIV Result by Demographic Characteristics among HIV Counseling and Testing Clients at the Nnamdi Azikiwe Teaching Hospital, Nnewi from December 2005 to May 2006
Abbreviation: HIV, human immunodeficiency virus.
Odds Ratio of HIV Results among HIV Counseling and Testing Clients at the Nnamdi Azikiwe Teaching Hospital, Nnewi from December 2005 to May 2006
Abbreviation: HIV, human immunodeficiency virus.
An interaction term between gender and marital status, with single male as reference, showed that chances of having a positive HIV test is highest in married females (OR, 6.70; 95% CI 4.45-10.09).
Discussion
The data points to high HIV risk among truck drivers. It also shows a generalized epidemic, particularly among married women who are “housewives.”
Being a long distance driver is a proven risk factor for HIV infection in Nigeria. 2 Though drivers in our cohort appear to be a mixture of intercity and long distance truck drivers.
The finding of housewives having higher chances of testing positive compared with farmers and technicians is interesting. The term “housewife” in the Nigerian society is sometimes used loosely to refer to women who are in nonpaid vocations and whose major preoccupation is taking care of the home. It is possible that these are women of lower socioeconomic status who are not in polygamous marriages as polygamy is not a common regional marital practice in this part of Nigeria. In order to understand fully this association, it will be necessary to correctly define the scope for a housewife in the Nnewi context.
Females, in this study, had a higher chance of testing positive for HIV. The chance was even higher in married females. This is not a strange finding for a place like Nigeria where the culture does not encourage condom negotiation in women and promotes many other practices that make women more vulnerable, putting them at higher risk of getting infected. 3
In general, being married constituted a higher risk for HIV in the crude and adjusted analysis. Data available was limited to “single” or “married.” Thus it was not possible to measure associations and impact of other categories such as widowed, divorced, or separated. These categories could give an insight into social circumstances that could possibly be related to HIV status as was observed in a study where widowed status was linked to being positive for HIV. 4
Unlike other studies which found that the age group 15 to 25 years was more commonly associated with high prevalence for HIV/AIDS, 5 –9 the risk was found to be lowest in this age group in our cohort. Students had a smaller chance of being HIV positive. Being single and young, one will expect students to have been having a high risk of testing positive. This positive effect could be a result of literacy level, or behavior change in communication being that this facility is affiliated with the university. This finding should be compared with findings in student populations in neighboring states. While younger patients in this review are not at risk as compared with married patients—there may be reasons besides those stated that account for this. The conclusion is not that they are not at risk.
Overall, HIV prevalence is extremely high. This could be because of nonavailability of other testing centers at Nnewi and the fact that services are offered free of charge. It will be necessary to establish a universal screening program across the town to map the rest of the untested population and a follow-up evaluation of reach and effectiveness of HCT services.
Limitations
This is a retrospective and hospital-based study. Therefore, results from analysis and conclusions cannot be generalized. Other limitations include the fact that information on residence, income level, and education and occupation of the clients especially those of the husbands were not available. Neither was there any information on sexual behaviors such number of sex partners or condom use. These will help to assess risk further.
Conclusion
The study succeeded in panning out an unexpected risk group: married women. Drivers have been known to be a risk group. The need to tailor activity for each risk group is obvious. There is a need to develop prevention interventions for truck drivers but also for women to be empowered to use condoms in their relationships. While younger patients in this review appear not at risk as compared with married patients, universal screening strategies should be considered across the board among this population in view of the high HIV prevalence.
Footnotes
Acknowledgments
The authors acknowledge the leadership and support of Prof Ofiaeli, project director of the ACTION Project; HIV counseling and testing by the HCT unit headed by Mrs Ngozi Ofiaeli; Dr Zoe Warrick (Brighton and Sussex University Hospitals Trust, Brighton) for looking over the first draft of data analysis; and Dr John Farley (Institute of Human Virology, Baltimore) also for looking over the first draft of the manuscript. The findings and conclusions in this publication are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receiving no financial support for the research, authorship, and/or publication of this article: The HIV counseling and testing services at Nnewi is supported by PEPFAR through cooperative agreement from HSS CDC Division of Global HIV AIDS to the University Of Maryland Institute Of Human Virology.