Determinants of Previous HIV Testing and Knowledge of Partner’s HIV Status Among Men Attending a Voluntary Counseling and Testing Clinic in Dar es Salaam,Tanzania

Abstract

Voluntary Counseling and Testing (VCT) remains low among men in sub-Saharan Africa. The factors associated with previous HIV testing and knowledge of partner’s HIV status are described for 9,107 men who visited the Muhimbili University College of Health Sciences’ VCT site in Dar es Salaam, Tanzania, between 1997 and 2008. Data are from intake forms administered to clients seeking VCT services. Most of the men (64.5%) had not previously been tested and 75% were unaware of their partner’s HIV status. Multivariate logistic regression revealed that age, education, condom use, and knowledge of partner’s HIV status were significant predictors of previous HIV testing. Education, number of sexual partners, and condom use were also associated with knowledge of partner’s HIV status. The low rate of VCT use among men underscores the need for more intensive initiatives to target men and remove the barriers that prevent HIV disclosure.

Keywords

HIV/AIDS quantitative research HIV testing HIV status

Introduction

In 2009, Africa accounted for 1.8 million of the 2.6 million new HIV infections that occurred worldwide (UNAIDS, 2010). Despite the aggressive promotion of Voluntary Counseling and Testing (VCT) services, a large number of infected individuals in Africa have not had an HIV test (Bunnell, Mermin, & De Cock, 2006; Kakoko, Åstrøm, Lugoe, & Lie, 2006). Furthermore, the risk of transmission remains high even within marriages because of the prevalence of extramarital affairs (Shisana et al., 2008). In response to the risks that are driving the HIV epidemic in Africa, prevention programs have widely promoted HIV testing and encouraged HIV-infected individuals to disclose their serostatus to their partner (Bunnell et al., 2006). Several VCT services in East African countries such as Uganda, Kenya, and Tanzania have implemented these recommendations but have not been successful in substantially increasing the proportion of men who seek VCT (Bwambale, Ssali, Byaruhanga, Kalyango, & Karamagi, 2008; Kairania et al., 2010; Miller & Rubin, 2007; Msuya et al., 2008).

According to the Tanzania HIV/AIDS and Malaria Indicator Survey, 6% of adults aged 15 to 49 years were infected with HIV in 2007-2008 (Tanzania Commission for AIDS, 2008). The spread of HIV in Tanzania has been attributed to the high rate of multiple sexual partners and the low rate of HIV testing (Tanzania Commission for AIDS, 2008). In 2007-2008, only 19% of women and men aged 15 to 49 years had been both tested for HIV and were aware of the results (Tanzania Commission for AIDS, 2008). From a public health perspective, knowledge of one’s own as well as a partner’s HIV status is imperative because it can lead to a decrease in risky sexual behavior and HIV infection (Allen et al., 1992). In addition, VCT serves as the gateway for HIV-positive people to benefit from increased access to antiretroviral treatment (Wringe et al., 2008). A study conducted among HIV discordant couples to assess the impact of VCT on condom use in Zambia revealed that men who learned of their positive HIV status were more likely to report 100% condom use than HIV-negative men (Allen et al., 2003). The authors suggested that the HIV-positive men intentionally used condom after becoming aware of their status to protect their uninfected partner. The effect of knowing one’s HIV status has also been shown to be associated with a reduction in sexual risk behaviors in the United States, with HIV-positive persons aware of their HIV status reporting a lower prevalence of unprotected anal or vaginal intercourse compared with HIV-positive persons unaware of their status (Marks, Crepaz, Senterfitt, & Janssen, 2005). These findings are similar to other studies showing that HIV-positive individuals who were aware of their partner’s HIV status were more likely to use condoms than those who were unaware (Bunnell et al., 2008; Benki-Nugent et al., 2011; Conserve, Sevilla, Younge, Mbwambo, & King, 2012).

In Tanzania, several studies have examined factors associated with VCT and HIV serostatus disclosure, but most of them have focused only on women (Antelman et al., 2001; de Paoli, Manongi, & Klepp, 2004; Kominami, Kawata, Ali, Meena, & Ushijima, 2007; Maman et al., 2002). A study of men attending a VCT clinic in Dar es Salaam indicates that some men view HIV testing as a cue to action to take precautionary preventive measures (Maman, Mbwambo, Hogan, Kilonzo, & Sweat, 2001). In another study carried out in the northern region of Tanzania, pregnant women (n = 2,654) were encouraged to invite their partners for VCT and only 12.5% of the men agreed to receive VCT (Msuya et al., 2008). The men were more likely to respond to their partner’s invitation if they had an older partner, lived with their partner or if their partner had a high monthly income, a history of treatment for STI symptoms, and intended to share their HIV results.

The low rate of VCT participation among men in Tanzania is alarming because previous studies have indicated that many men in Africa engage in risky sexual behaviors that place themselves and their partner at risk. For example, it has been reported that men in Tanzania and Nigeria seek extramarital sexual partners to increase their sense of masculinity and self-esteem when faced with situations, such as unemployment, that prevent them from fulfilling the role of provider and meeting the needs of their family (Oyediran, Isiugo-Abanihe, Feyisetan, & Ishola, 2010; Silberschmidt, 2001; Smith, 2007). In another study conducted among 584 married men in Mbeya, one of the regions with the highest HIV prevalence in Tanzania, 39% of the participants reported to have had sex with women other than their wives (Mbago & Sichona, 2011). A recent study revealed that that the only risky behavior associated with HIV among men in Tanzania was the number of sexual partners in the last 3 years (Ghebremichael & Paintsil, 2011).

Increasing the number of men who receive VCT services is crucial in curbing the AIDS epidemic in Africa. Some of the factors underlying the risky sexual behaviors of men are related to gender role norms that encourage men to be sexually active and to have multiple partners as a rite of passage to adulthood (Barker & Ricardo, 2005). Furthermore, the well-documented gender power imbalance in sexual relations that exists in many African countries also reduces a woman’s ability to negotiate safer sex as many men refuse to use condoms despite having multiple sexual partners (Langen, 2007). These contemporary gender roles also influence women’s ability to seek VCT services and prevent some women from sharing their serostatus with their partners (Peacock & Levack, 2004). In Dar es Salaam, it was reported that women’s fear of their partners’ reactions was the most common barrier to HIV testing and that the men needed to give the women permission prior to attending the VCT clinic (Maman et al., 2001).

Considering the low rate of VCT participation, the high rate of risky behaviors reported among males, and the important role men play in their households, it is crucial to investigate HIV testing behaviors of men. The present study examines the association between sociodemographic factors, number of sexual partners, condom use, and previous HIV testing as well as knowledge of partner’s HIV status among men who had sex in the past 6 months.

Method

Procedures

Data for this analysis were collected from clients seeking HIV testing between 1997 and 2008 at the Muhimbili University College of Health Sciences’ Voluntary Counseling and Testing clinic in Dar es Salaam, Tanzania. A total of 45,071 men and women were selected through convenience sampling to complete the intake form that was self-administered in Kiswahili and translated into English. To ensure that people who had multiple visits were only included once in the data set, the client ID was used to sort individuals by date of clinic attendance and the first observation (earliest date) was kept. Of the 45,071 clients, 22,808 were excluded because they were females, 8,716 were not included because they were less than 15 years old and had not engaged in sexual intercourse in the past 6 months. The remaining 4,440 were excluded due to missing data, leaving a total of 9,107 men who met all the criteria and completed all the questions for the variables used in this analysis. The form inquired about sociodemographic characteristics, HIV testing history and serostatus of the clients and their sexual partner, sexual practices, and condom use in the previous 6 months. Although some men had multiple permanent sexual partners, they only needed to know at least one of their permanent partner’s HIV status to be included in this analysis. In addition, men were also questioned about casual sexual partners; however, the majority (6,986) of the men reported that they did not have a casual partner. Therefore, there were not enough men with casual sexual partners to include in the analysis. The HIV status of the men was confirmed with the results of a Capillus HIV test.

Variables

The first outcome variable measured the men’s history of HIV testing prior to visiting the clinic. To determine testing history, clients were asked whether they had been tested for HIV. The variable was coded as follows: (1) no; (2) yes, it was negative; and (3) yes, it was positive. The second outcome variable inquired if the men’s partner had been tested for HIV and was coded as follows: (0) no; (1) yes, it was negative; (2) yes, it was positive; (3) yes, but the result was unknown; and (4) I do not know. Clients were categorized as having had an HIV test if they reported both that they had been tested and knew their HIV status. Men whose partner had been tested and knew their partner’s test result were categorized as being aware of their partner’s HIV status, whereas those whose partner had not been tested or did not know their partner’s HIV status were considered unaware.

The independent variables included sociodemographic characteristics, number of sexual partners, and condom use in the past 6 months. Individuals reported their gender (male/female). The age variable was categorized (15-25 years, 26-36 years, 37-47 years, and 48 years and older) to explore how certain stages of the life cycle such as adolescence, young adult, and adults influence previous HIV testing. This categorization was also based on the evidence that Tanzanian men in the 25 to 29 and 30 to 39 age ranges are more likely to know where to get an HIV test (Tanzania Commission for AIDS, 2008). The education variable was divided into five ascending education categories: no education, primary education, secondary, postsecondary, and university. In Tanzania, the official school attending age ranges from 7 to 13 years for primary, 14 to 19 years for secondary, and 20 to 24 years for postsecondary education (Ministry of Education and Vocational Training, 2010). Respondents reported their marital status to the enumerator; however, because of the limited number of individuals in certain categories, this variable was recoded accordingly: single, married, or divorced. Based on the reported number of children, a binary variable was created to designate the presence or absence of dependents. Responses to the question about the number of permanent sexual partners were categorized as one partner and two or more partners. Condom use was assessed by the following question: Did you use a condom during sex in the past 6 months? Responses for condom use were no, sometimes, always, and not applicable. Respondents who reported not using or sometimes using condoms in the past 6 months were combined as neither group reported consistently using condoms, and thus the risk of infecting their HIV-negative partners was high in both groups.

Statistical Analysis

The analyses consisted of univariate, bivariate, and multivariate analyses. Basic frequencies were used to describe the distribution of the sociodemographic variables, history of HIV testing, knowledge of partner’s HIV status, and behavioral variables. Due to the small percentage of HIV-positive men and those with an HIV-positive partner, the recoded versions of the two outcome variables, HIV testing (no vs. yes) and knowledge of partner’s HIV status (unaware vs. aware), were used in the bivariate and multivariate analyses. Cross-tabulation analysis between HIV testing, knowledge of partner’s HIV status, and sociodemographic and behavioral variables was performed. Last, the variables that were significant in the bivariate analyses were included in the multivariate logistic regression models to examine predictors of HIV testing and knowledge of partner’s HIV status. Separate analyses for years 1997-2002 and 2003-2008 were run to investigate if the same variables predicted the two outcomes. The majority of the significant variables for the different time frame were similar to the variables for the combined years. Therefore, only the findings for the combined years were reported. All analyses were performed using SPSS for Windows, Version 20 (IBM SPSS Inc., Chicago, IL).

Results

The sample consisted of 9,107 men with an average age of 34.3 years, and 3,201 (35%) of the men had a secondary education (Table 1). Approximately 4,700 (52%) reported being married and 5,272 (57.9%) had a child. Consistent condom use was low (n = 589; 6.5%), and 5,872 (64.5%) of the men had not previously been tested before visiting the clinic. Among those who had been tested, 3,051 (33.5%) reported they were HIV negative and 184 (2%) were HIV positive. Similarly, three quarters (n = 6,836; 75.1%) of the men were unaware of their partner’s HIV status, and 1,973 (21.7%) had an HIV-negative partner whereas 298 (3.3%) had an HIV-positive partner.

Table 1.

Demographic Characteristics of Men Who Had Sex in the Past 6 Months

	Frequency (n = 9,107)	%
Age range
15-25	1,467	16.1
26-36	4,599	50.5
37-47	2,126	23.3
48 and older	915	10.0
Education
No education	189	2.1
Primary	3,589	39.4
Secondary	3,201	35.1
Postsecondary	1,184	13.0
University	944	10.4
Marital status
Single	4,049	44.5
Married	4,753	52.2
Divorced	305	3.3
Number of sexual partners
One	8,381	92.0
Two or more	726	8.0
Condom use
Inconsistent	8,518	93.5
Consistent	589	6.5
Children
No	3,835	42.1
One or more	5,272	57.9
Previous HIV test and status
No	5,872	64.5
Yes, it was negative	3,051	33.5
Yes, it was positive	184	2.0
Knowledge of partner’s HIV status
No	6,836	75.1
Yes, it was negative	1,973	21.7
Yes, it was positive	298	3.3

As reported in Table 2, men in older age categories were significantly more likely to have been tested than the men in the 15- to 25-year-old category (χ² = 85.8, p < .001). A previous HIV test was positively associated with education, as it was lowest (n = 49; 25.9%) among men without any formal education and highest (n = 537; 56.9%) among university educated men (χ² = 337.5, p < .001). Compared with men with one sexual partner, men with two or more sexual partners were significantly less likely to have been tested (χ² = 22, p < .001). Differences by condom use were relatively large, with 323 (54.8%) consistent condom users reporting a previous HIV test compared with 2,912 (34.2%) inconsistent condom users (χ² = 102.6, p < .001). The largest difference in HIV testing was between men who were aware (n = 1,447; 63.7%) and men who were unaware (n = 1,788; 26.2%) of their partner’s HIV status (χ² = 1,050, p < .001).

Table 2.

Characteristics of Men Who Had Sex in the Past 6 Months by Previous HIV Test and Knowledge of Partner’s HIV Status

	Number (%) of men who reported HIV test, n = 3,235 (35.5%)	Number (%) of men aware of partner’s HIV status, n = 2,271 (24.9%)
Age range
15-25	368 (25.1)***	244 (16.6)***
26-36	1,747 (38.0)	1,205 (26.2)
37-47	768 (36.1)	595 (28.0)
48 and older	352 (38.5)	227 (24.8)
	χ² = 85.8	χ² = 68.5
Education
No education	49 (25.9)***	27 (14.3)***
Primary	965 (26.9)	713 (19.9)
Secondary	1,187 (37.1)	852 (26.6)
Postsecondary	497 (42.0)	319 (26.9)
University	537 (56.9)	360 (38.1)
	χ² = 337.5	χ² = 156
Marital status
Single	1,415 (34.9)	835 (20.6)***
Married	100 (36.2)	68 (22.3)
Divorced	1,720 (32.8)	1,368 (28.8)
	Not significant	χ² = 79
Number of sexual partners
One	3,035 (36.2)***	2,166 (25.8)***
Two or more	200 (27.5)	105 (14.5)
	χ² = 22	χ² = 46.2
Condom use
Inconsistent	2,912 (34.2)***	2,074 (24.3)***
Consistent	323 (54.8)	197 (33.4)
	χ² = 102.6	χ² = 24.4
Children
None	1,349 (35.2)	846 (22.1)***
One or more	1,886 (35.8)	1,425 (27.0)
	Not significant	χ² = 29.3
Previous HIV test
No		824 (14.0)***
Yes		1,447 (44.7)
		χ² = 1,050
Knowledge of partner’s HIV status
Unaware	1,788 (26.2)***
Aware	1,447 (63.7)
	χ² = 1,050

Note. Only men who had been tested for HIV and those who are aware of their partner’s HIV status are reported in this table.

***

p < .001.

Similarly, men in older age categories were more likely to be aware of their partner’s HIV status than men in the 15- to 25-year-old category (χ² = 68.5, p < .001). As education increased, awareness of partner’s HIV status also increased (χ² = 156.0, p < .001). Men with one sexual partner were significantly more likely (n = 2,166; 25.8%) to be aware of their partner’s HIV status than men with two or more sexual partners (n = 105; 14.5%; χ² = 46.2, p < .001). Awareness of a partner’s HIV status was more common among consistent condom users (n = 197; 33.4%) than inconsistent condom users (n = 2,074; 24.3%; χ² = 24.4, p < .001) and men with children (n = 1,425; 27%) than men without children (n = 846; 22.1%; χ² = 29.3, p < .001). The proportion of men who were aware of their partner’s HIV status was significantly higher (n = 1,447; 44.7%) among men who reported a history of HIV testing than men who had not been tested (n = 824; 14%; χ² = 1050, p < .001).

Multivariate logistic regression model indicated that men in the 26 to 36, 37 to 47, and 48 and older age categories were significantly more likely to have been tested compared with those younger than 26 years old: odds ratio (OR) = 1.58, 95% confidence interval (CI) = 1.37, 1.81; OR = 1.53, 95% CI = 1.31, 1.80; and OR = 1.80, 95% CI = 1.48, 2.17, respectively (Table 3). Men with a secondary, postsecondary, and university education were more likely to have been tested compared with men with no formal education: OR = 1.47, 95% CI = 1.04, 2.09; OR = 1.85, 95% CI = 1.28, 2.66; OR = 2.82, 95% CI = 1.95, 4.07, respectively. Consistent condom use and knowledge of partner’s HIV status were also significant predictors of HIV testing, with adjusted ORs of 2.12 (95% CI = 1.77, 2.55) and 4.53 (95% CI = 4.08, 5.03), respectively. Surprisingly, men with two or more sexual partners were no more likely to have been tested than men with one sexual partner.

Table 3.

Multiple Logistic Regression Analysis of HIV Test Prior to Visiting VCT Clinic (Lower and Upper 95% CI Limits)

Variables	Unadjusted ORs (95% CI)	Adjusted ORs (95% CI)
Age range
15-25	1***	1***
26-36	1.83 (1.60, 2.09)	1.58 (1.37,1.81)
37-47	1.69 (1.46, 1.96)	1.53 (1.31, 1.80)
48 and older	1.87 (1.56, 2.23)	1.80 (1.48, 2.17)
Education
No education	1***	1***
Primary	1.05 (0.75, 1.47)	0.97 (0.69, 1.38)
Secondary	1.68 (1.21, 2.35)	1.47 (1.04, 2.09)
Postsecondary	2.07 (1.46, 2.92)	1.85 (1.28, 2.66)
University	3.77 (2.66, 5.35)	2.82 (1.95, 4.07)
Number of sexual partners
One	1***	1
Two or more	0.67 (0.56, 0.79)	0.84 (0.70, 1.01)
Condom use
Inconsistent	1***	1***
Consistent	2.34 (1.98, 2.77)	2.12 (1.77, 2.55)
Knowledge of partner’s HIV status
Unaware	1***	1***
Aware	4.96 (4.48, 5.49)	4.53 (4.08, 5.03)

Note. VCT = Voluntary Counseling and Testing; OR = odds ratio; CI = confidence interval.

***

p < .001.

The multivariate logistic regression model for knowledge of partner’s HIV status showed that the adjusted ORs were statistically significant for university-educated men (OR = 2.84, 95% CI = 1.81, 4.45) compared with men with no formal education and for married men (OR = 1.81, 95% CI = 1.55, 2.10) versus single men (Table 4). Men who had two or more sexual partners were significantly less likely (OR = 0.54, 95% CI = 0.43, 0.67) to be aware of their partner’s HIV status than men with one sexual partner. Consistent condom users had a greater likelihood (OR = 1.27, 95% CI = 1.04, 1.54) of being aware of their partner’s HIV status compared with inconsistent condom users. As expected, men who had been tested were far more likely (OR = 4.57, 95% CI = 4.12, 5.08) to be aware of their partner’s HIV status than men with no history of HIV testing.

Table 4.

Multiple Logistic Regression Analysis of Knowledge of Partner’s HIV Status (Lower and Upper 95% CI Limits)

Variables	Unadjusted ORs (95% CI)	Adjusted ORs (95% CI)
Age range
15-25	1***	1
26-36	1.78 (1.53, 2.07)	1.17 (0.98, 1.39)
37-47	1.95 (1.65, 2.30)	1.11 (0.90, 1.38)
48 and older	1.65 (1.35, 2.03)	0.86 (0.66, 1.10)
Education
No education	1***	1***
Primary	1.49 (0.98, 2.25)	1.55 (1.01, 2.40)
Secondary	2.18 (1.44, 3.30)	2.15 (1.39, 3.32)
Postsecondary	2.21 (1.44, 3.40)	2.04 (1.30, 3.19)
University	3.70 (2.41, 5.68)	2.84 (1.81, 4.45)
Marital status
Single	1***	1***
Married	1.56 (1.41, 1.72)	1.81 (1.55, 2.10)
Divorced	1.10 (0.84, 1.46)	1.31 (0.95, 1.80)
Number of sexual partners
One	1***	1***
Two or more	0.49 (0.39, 0.60)	0.54 (0.43, 0.67)
Condom use
Inconsistent	1***	1*
Consistent	1.56 (1.31, 1.87)	1.27 (1.04, 1.54)
Children
None	1***	1
One or more	1.31 (1.19, 1.44)	1.02 (.88, 1.19)
Previous HIV test
No	1***	1***
Yes	4.96 (4.48, 5.48)	4.57 (4.12, 5.08)

Note. OR = odds ratio; CI = confidence interval.

p < .05. ***p < .001.

Discussion

To our knowledge, this is the first study to use data collected over 11 years to assess predictors of HIV testing and knowledge of partner’s HIV status among Tanzanian men. Overall, there was a low rate of previous HIV testing and 2% of the men reported being HIV positive before visiting the clinic. Only 35% of the men had been tested at least once prior to visiting the clinic. Our finding supports studies that have reported a relatively low rate of male VCT participation in other African countries (deGraft-Johnson, Paz-Soldan, Kasote, & Tsui, 2005). In one study conducted in a South African province, the authors examined HIV testing records in 282 VCT sites and identified that 72.7% of those tested for HIV from 1998 to 006 were females (Snow, Madalane, & Poulsen, 2010). Similarly, a study conducted among 780 men in Uganda revealed that only 23.3% of the men had completed the process of pretest counseling, HIV testing, posttest counseling, and receiving their HIV test results (Bwambale et al., 2008). The lower proportion of men who had been tested after nearly three decades of the HIV epidemic indicates the need for prevention efforts in Africa to aggressively target men.

Compared with younger men, older men were more likely to have been tested. The greater likelihood of older men to have been tested differs from previous studies (Gage & Ali, 2005; Kranzer et al., 2011). One explanation for young men being less likely to have been tested may be the fact that they are also less likely to know where to get tested (Tanzania HIV/AIDS and Malaria Indicator Survey, 2008). It can also be that older men have higher HIV-related knowledge and have had more time to get tested than younger men (Jean, Anglaret, Moh, Lert, & Dray-Spira, 2012). Previous HIV testing was also more common among men with an increasing level of education. Other studies have reported similar results in Bostwana and South Africa (Kalichman & Simbayi, 2003; Weiser et al., 2006). The higher rate of HIV testing among the most educated may be a result of their prolonged exposure to HIV prevention messages, which are more readily available in the school system than in the community (Hargreaves et al., 2008). Previous research indicates that more educated men are more likely to engage in risky sexual behavior (Kongnyuy, Wiysonge, Mbu, Nana, & Kouam, 2006). Therefore, the authors suggest the finding which reveals that more educated men are more likely to seek HIV testing may also be a result of their greater concern regarding the risk of HIV due to their sexual behavior. In addition, a person’s educational level can determine knowledge and interest in health issues and increase their access to health care and utilization of care, which in turn would influence the likelihood of having been tested for HIV (Bond, Lauby, & Batson, 2005). Education was also positively correlated with knowledge of partner’s HIV status. It is plausible that since men with more years of education are more likely to get tested, their partners are also more likely to seek VCT and disclose their HIV status.

Knowledge of partner’s HIV status among men can be influenced by an array of individual, relational, and environmental factors such as their attitudes toward HIV testing, decision making and communication patterns with their partners, and most importantly whether their partner has been tested (Maman et al., 2001). Many of the men in this study were not aware (75.1%) of their partner’s HIV status. The lack of awareness of partner’s HIV status reflects the possibility that a majority of the men’s partners may also be unaware of their own status because they have not been tested. It may also be the case that some of the women have been tested for HIV without informing the men. It was reported that in Dar es Salaam whereas men who participated in VCT had no fear disclosing their results, the situation was different for women, some of whom risked being abandoned or verbally and physically abused by their partner (Maman et al., 2001).

Our finding confirms the low rate (20% to 40%) of disclosure that was reported among 1,078 HIV-positive pregnant women who participated in a randomized controlled study in Dar es Salaam (Antelman et al., 2001). To increase knowledge of partner’s HIV status among men in Tanzania, prevention programs that provide VCT services need to provide women with adequate support that can assist them with the disclosure process and protect them from any violence that may ensue (Maman et al., 2002). Culturally sanctioned gender roles have been associated with sexual violence against women, reducing their ability to protect themselves from STI/HIV, and personal control over their use of health services (Carey et al., 2011; Dunkle et al., 2004; Kalichman et al., 2005; Peacock & Levack, 2004; Susser & Stein, 2000). VCT clinics should promote couples voluntary counseling and testing because it has been shown to be more cost-effective in helping couples learn about their and their partner’s HIV status with the assistance of a professional and lead to greater protected sexual intercourse when compared with individual HIV voluntary counseling and testing (Becker, Mlay, Schwandt, & Lyamuya, 2010; Coates, 2000; Desgrées-du-Loû & Orne-Gliemann, 2008; Sweat et al., 2000).

Finally, HIV testing and awareness of partner’s HIV status was more common among men who had consistently used a condom in the past 6 months. One possible explanation for this finding is that the counseling that went along with testing may have led to an increase in condom use and partner communication regarding HIV serostatus (Bentley et al., 1998). Alternatively, this finding may be related to a greater concern about health among those who have tested, which would motivate them to use condoms and learn about their partner’s HIV status. The increase in condom use among those who were aware of their partner’s HIV status support previous studies from Tanzania, Uganda, and South Africa, which reported that adults who used condoms were more likely to be aware of their partner’s HIV status than individuals who did not use condoms (Bunnell et al., 2008; Conserve et al., 2012; King et al., 2008; Olley, Seedat, Gxamza, Reuter, & Stein, 2005).

Contrary to what may be expected, men with two or more sexual partners were both less likely to have been tested and to be aware of their partners’ HIV status. Although only one of these findings was significant, it does indicate that men with the riskiest behaviors are least likely to seek VCT. Our results, however, are consistent with a recent study that reveals that although men with multiple sexual partners understand their behavior increases their likelihood of HIV infection, those who perceive themselves at high risk of HIV do not seek testing (Johnston et al., 2010). Men with multiple sexual partners may associate their behavior with risk taking, which is often endorsed as a characteristic of masculinity (Towsend et al., 2011, Shai, Jewkes, Nduna, & Dunkle, 2012).

The strengths of our study include the large sample size collected over a period of 11 years, inclusion of men residing in the region with the second highest HIV prevalence rate, and ability to compare VCT attendance among inconsistent condom users to consistent condom users and men aware of their partner’s HIV serostatus to those unaware. Considering the analysis only included men already seeking VCT services, the results of this study may not be generalizable to all men in Tanzania, as they may different from the men who seek VCT services. Data were collected only in Dar es Salaam and the intake form did not inquire about sexual orientation. VCT practices could vary if examined among men in other regions and those who have sex with men (Nyoni & Ross, 2012; Wringe et al., 2008). The use of client’s self-report for their previous HIV test history, knowledge of their partner’s HIV status, and the number of sexual partners may have led to social desirability and recall bias. An underreporting of VCT attendance may also have occurred due to item nonresponse. Although much research have been conducted to examine the effects of awareness of one’s own and partner’s HIV status on sexual behavior, fewer studies have investigated the concordance between individual’s perceived and actual partners’ HIV status (Brown et al., 2011; Niccolai, Farley, Ayoub, Magnus, & Kissinger, 2002; Witte, El-Bassel, Gilbert, Wu, & Chang, 2010). Future research should include males’ sexual partners and measurement of the accuracy of knowledge of partner’s HIV status, and sexual behaviors.

In conclusion, these findings suggest the need for the Tanzanian government as well as other African countries to ensure that the HIV/AIDS testing campaign increasingly direct their efforts toward men who are younger, less educated, and have multiple sexual partners. These efforts could not only increase the number of men who seek VCT but also encourage men to protect themselves and in turn reduce the number of new infections in Africa. In addition, increasing the number of men who uses VCT services is crucial in curbing the HIV epidemic in Tanzania because men are the heads of households and can influence whether their partner has access to HIV prevention and care resources (Bwambale et al., 2008).

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 following financial support for the research, authorship, and/or publication of this article: This research was supported by the Minority Health and Health Disparities International Research Training Program of National Institute of Minority Health and Health Disparities # 5 T 37 TW00113-08 and National Institute of Mental Health-COR Grant # MH-16573.

References

Allen

Meinzen-Derr

Kautzman

Zulu

Trask

Fideli

Haworth

(2003). Sexual behavior of HIV discordant couples after HIV counseling and testing. AIDS, 17, 733-740.

Allen

Serufilira

Bogaerts

Van

Perre

Nsengumuremyi

Lindan

Hulley

(1992). Confidential HIV testing and condom promotion in Africa. Journal of the American Medical Association, 268, 3338-3343.

Antelman

Smith Fawzi

M. C.

Kaaya

Mbwambo

Msamanga

G. I.

Hunter

D. J.

Fawzi

W. W.

(2001). Predictors of HIV-1 serostatus disclosure: A prospective study among HIV-infected pregnant women in Dar es Salaam, Tanzania. AIDS, 15, 1865-1874.

Barker

Ricardo

(2005). Young men and the construction of masculinity in sub-Saharan Africa: Implications for HIV/AIDS, conflict, and violence. Washington, DC: The World Bank.

Becker

Mlay

Schwandt

H. M.

Lyamuya

(2010). Comparing couples’ and individual voluntary counseling and testing for HIV at antenatal clinics in Tanzania: A randomized trial. AIDS and Behavior, 14, 558-566.

Benki-Nugent

Chung

M. H.

Ackers

Richardson

B. A.

McGrath

C. J.

Kohler

John-Stewart

G. C.

(2011). Knowing a sexual partner is HIV-1-uninfected is associated with higher condom use among HIV-1-infected adults in Kenya. Sexually Transmitted Diseases, 38, 808-810.

Bentley

M. E.

Spratt

Shepherd

M. E.

Gangakhedkar

R. R.

Thilikavathi

Bollinger

R. C.

Mehendale

S. M.

(1998). HIV testing and counseling among men attending sexually transmitted disease clinics in Pune, India: Changes in condom use and sexual behavior over time. AIDS, 12, 1869-1877.

Bond

Lauby

Batson

(2005). HIV testing and the role of individual- and structural-level barriers and facilitators. AIDS Care, 17, 125-140.

Brown

L. B.

Miller

W. C.

Kamanga

Nyirenda

Mmodzi

Pettifor

Martinson

(2011). HIV partner notification is effective and feasible in sub-Saharan Africa: Opportunities for HIV treatment and prevention. JAIDS: Journal of Acquired Immune Deficiency Syndromes, 56, 437-442.

10.

Bunnell

Mermin

De Cock

K. M.

(2006). HIV prevention for a threatened continent. Journal of the American Medical Association, 296, 855-858.

11.

Bunnell

Opio

Musinguzi

Kirungi

Ekwaru

Mishra

Mermin

(2008). HIV transmission risk behavior among HIV-infected adults in Uganda: Results of a nationally representative survey. AIDS, 22, 617-624.

12.

Bwambale

Ssali

Byaruhanga

Kalyango

Karamagi

(2008). Voluntary HIV counselling and testing among men in rural western Uganda: Implications for HIV prevention. BMC Public Health, 8(1), 263.

13.

Carey

K. B.

Scott-Sheldon

L. A. J.

Carey

M. P.

Cain

Mlobeli

Vermaak

Kalichman

S. C.

(2011). Community norms for HIV risk behaviors among men in a South African township. Journal of Behavioral Medicine, 34(1), 32-40.

14.

Coates

T. J.

(2000). Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: A randomised trial. Lancet (British Edition), 356, 103-112.

15.

Conserve

Sevilla

Younge

Mbwambo

King

(2012). Condom use among HIV positive sexually active adults and partner’s HIV status in Dar es Salaam, Tanzania. Journal of Health Care for the Poor and Underserved, 23, 191-203.

16.

de Paoli

M. M.

Manongi

Klepp

K. I.

(2004). Factors influencing acceptability of voluntary counselling and HIV-testing among pregnant women in Northern Tanzania. AIDS Care, 16, 411-425.

17.

deGraft-Johnson

Paz-Soldan

Kasote

Tsui

(2005). HIV voluntary counseling and testing service preferences in a rural Malawi population. AIDS and Behavior, 9, 475-484.

18.

Desgrées-du-Loû

Orne-Gliemann

(2008). Couple-centred testing and counselling for HIV serodiscordant heterosexual couples in sub-Saharan Africa. Reproductive Health Matters, 16, 151-161. doi:10.1016/s0968-8080(08)32407-0

19.

Dunkle

K. L.

Jewkes

R. K.

Brown

H. C.

Gray

G. E.

McIntryre

J. A.

Harlow

S. D.

(2004). Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet, 363, 1415-1421. doi:10.1016/s0140-6736(04)16098-4

20.

Gage

A. J.

Ali

(2005). Factors associated with self-reported HIV testing among men in Uganda. AIDS Care, 17, 153-165.

21.

Ghebremichael

Paintsil

(2011). High risk behaviors and sexually transmitted infections among men in Tanzania. AIDS and Behavior, 15, 1026-1032.

22.

Hargreaves

J. R.

Bonell

C. P.

Boler

Boccia

Birdthistle

Fletcher

Glynn

J. R.

(2008). Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS, 22, 403-414.

23.

Jean

Anglaret

Moh

Lert

Dray-Spira

(2012). Barriers to HIV testing in Côte d’Ivoire: The role of individual characteristics and testing modalities. PLoS ONE, 7(7), e41353. doi:10.1371/journal.pone.0041353

24.

Johnston

O’Bra

Chopra

Mathews

Townsend

Sabin

Kendall

(2010). The associations of voluntary counseling and testing acceptance and the perceived likelihood of being HIV-infected among men with multiple sex partners in a South African township. AIDS and Behavior, 14, 922-931.

25.

Kairania

Gray

R. H.

Kiwanuka

Makumbi

Sewankambo

N. K.

Serwadda

Wawer

M. J.

(2010). Disclosure of HIV results among discordant couples in Rakai, Uganda: A facilitated couple counselling approach. AIDS Care, 22, 1041-1051.

26.

Kakoko

D. C.

Åstrøm

Lugoe

W. L.

Lie

G. T.

(2006). Predicting intended use of voluntary HIV counselling and testing services among Tanzanian teachers using the theory of planned behaviour. Social Science & Medicine, 63, 991-999.

27.

Kalichman

S. C.

Simbayi

L. C.

(2003). HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a Black township in Cape Town, South Africa. Sexually Transmitted Infections, 79, 442-447.

28.

Kalichman

S. C.

Simbayi

L. C.

Kaufman

Cain

Cherry

Jooste

Mathiti

(2005). Gender attitudes, sexual violence, and HIV/AIDS risks among men and women in Cape Town, South Africa. Journal of Sex Research, 42, 299-305. doi:10.1080/00224490509552285

29.

King

Katuntu

Lifshay

Packel

Batamwita

Nakayiwa

Johansson

(2008). Processes and outcomes of HIV serostatus disclosure to sexual partners among people living with HIV in Uganda. AIDS and Behavior, 12, 232-243.

30.

Kominami

Kawata

Ali

Meena

Ushijima

(2007). Factors determining prenatal HIV testing for prevention of mother to child transmission in Dar Es Salaam, Tanzania. Pediatrics International, 49, 286-292.

31.

Kongnyuy

Wiysonge

Mbu

Nana

Kouam

(2006). Wealth and sexual behaviour among men in Cameroon. BMC International Health and Human Rights, 6(1), 11.

32.

Kranzer

van Schaik

Karmue

Middelkoop

Sebastian

Lawn

S. D.

. (2011). High Prevalence of Self-Reported Undiagnosed HIV despite High Coverage of HIV Testing: A Cross-Sectional Population Based Sero-Survey in South Africa. PloS one, 6(9).

33.

Langen

T. T.

(2007). Gender power imbalance on women’s capacity to negotiate self-protection against HIV/AIDS in Botswana and South Africa. African Health Sciences, 5, 188-197.

34.

Maman

Mbwambo

J. K.

Hogan

N. M.

Kilonzo

G. P.

Campbell

J. C.

Weiss

Sweat

M. D.

(2002). HIV-positive women report more lifetime partner violence: Findings from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania. Journal Information, 92, 1331-1337.

35.

Maman

Mbwambo

J. K.

Hogan

N. M.

Kilonzo

G. P.

Sweat

(2001). Women’s barriers to HIV-1 testing and disclosure: Challenges for HIV-1 voluntary counselling and testing. AIDS Care, 13, 595-603.

36.

Marks

Crepaz

Senterfitt

J. W.

Janssen

R. S.

(2005). Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: Implications for HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes, 39, 446-453.

37.

Mbago

M. C. Y.

Sichona

F. J.

(2011). Determinants of extramarital sex by men in Tanzania: A case study of Mbeya region. Journal of Social Aspects of HIV/AIDS Research Alliance, 7(4), 33-38.

38.

Miller

A. N.

Rubin

D. L.

(2007). Motivations and methods for self-disclosure of HIV seropositivity in Nairobi, Kenya. AIDS and Behavior, 11, 687-697.

39.

Ministry of Education and Vocational Training. (2010). Basic education statistics in Tanzania, 2006-2010. Retrieved from http://www.tzonline.org/news.asp?ItemID=241&pcid=87&cid=88&archive=yes

40.

Msuya

Mbizvo

Hussain

Uriyo

Sam

Stray-Pedersen

(2008). Low male partner participation in antenatal HIV counselling and testing in northern Tanzania: Implications for preventive programs. AIDS Care, 20, 700-709.

41.

Niccolai

L. M.

Farley

T. A.

Ayoub

M. A.

Magnus

Kissinger

P. J.

(2002). HIV-infected persons’ knowledge of their sexual partners’ HIV status. AIDS Education and Prevention, 14, 183-189.

42.

Nyoni

Ross

M. W.

(2012). Factors associated with HIV testing in men who have sex with men, in Dar es Salaam, Tanzania. Sexually Transmitted Infections. Advance online publication. doi:10.1136/sextrans-2012-050661

43.

Olley

B. O.

Seedat

Gxamza

Reuter

Stein

(2005). Determinants of unprotected sex among HIV-positive patients in South Africa. AIDS Care, 17, 1-9.

44.

Oyediran

Isiugo-Abanihe

U. C.

Feyisetan

B. J.

Ishola

G. P.

(2010). Prevalence of and factors associated with extramarital sex among Nigerian men. American Journal of Men’s Health, 4, 124-134.

45.

Peacock

Levack

(2004). The men as partners program in South Africa: Reaching men to end gender-based violence and promote sexual and reproductive health. International Journal of Men’s Health, 3, 173-188.

46.

Shai

N. J.

Jewkes

Nduna

Dunkle

(2012). Masculinities and condom use patterns among young rural South Africa men: A cross-sectional baseline survey. BMC Public Health, 12(1), 462.

47.

Shisana

Zungu-Dirwayi

Toefy

Simbayi

Malik

Zuma

(2008). Marital status and risk of HIV infection in South Africa. South African Medical Journal, 94, 537-543.

48.

Silberschmidt

(2001). Disempowerment of men in rural and urban East Africa: Implications for male identity and sexual behavior. World Development, 29, 657-671.

49.

Smith

D. J.

(2007). Modern marriage, men’s extramarital sex, and HIV risk in southeastern Nigeria. American Journal of Public Health, 97, 997-1005.

50.

Snow

Madalane

Poulsen

(2010). Are men testing? Sex differentials in HIV testing in Mpumalanga Province, South Africa. AIDS Care, 22, 1060-1065.

51.

Susser

Stein

(2000). Culture, sexuality, and women’s agency in the prevention of HIV/AIDS in southern Africa. American Journal of Public Health, 90, 1042-1048.

52.

Sweat

Gregorich

Sangiwa

Furlonge

Balmer

Kamenga

Coates

(2000). Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania. Lancet, 356, 113-121.

53.

Tanzania Commission for AIDS, Zanzibar AIDS Commission (ZAC), National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and Macro International, Inc. (2008). Tanzania HIV/AIDS and Malaria Indicator Survey 2007-08. Retrieved from http://www.tacaids.go.tz/dmdocuments/THMIS%202007-08.pdf

54.

Townsend

Jewkes

Mathews

Johnston

Flisher

Zembe

Chopra

(2011). HIV risk behaviours and their relationship to intimate partner violence (IPV) among men who have multiple female sexual partners in Cape Town, South Africa. AIDS and Behavior, 15, 132-141. doi:10.1007/s10461-010-9680-5

55.

UNAIDS. (2010). A report on the global AIDS epidemic. Geneva, Switzerland: Author.

56.

Weiser

S. D.

Heisler

Leiter

Percy-de Korte

Tlou

DeMonner

Iacopino

(2006). Routine HIV testing in Botswana: A population-based study on attitudes, practices, and human rights concerns. PLoS Medicine, 3, e261.

57.

Witte

S. S.

El-Bassel

Gilbert

Chang

(2010). Lack of awareness of partner STD risk among heterosexual couples. Perspectives on Sexual and Reproductive Health, 42(1), 49-55.

58.

Wringe

Isingo

Urassa

Maiseli

Manyalla

Changalucha

Zaba

(2008). Uptake of HIV voluntary counselling and testing services in rural Tanzania: Implications for effective HIV prevention and equitable access to treatment. Tropical Medicine & International Health, 13, 319-327.