Demand-creation for couples’ HIV counselling and testing among married or cohabiting individuals in Rakai, Uganda: Trends, motivations, barriers and intervention outcomes

Abstract

Introduction: Couples’ HIV counselling and testing (couples’ HCT) can improve identification of undiagnosed HIV infections and promote timely linkage and retention into HIV care among HIV- discordant and concordant HIV positive couples. Couples’ HCT can also enhance primary HIV prevention by improving communication between partners and linking them to appropriate HIV prevention services. Despite these benefits, fewer than 30% of married or cohabiting individuals have ever tested as a couple, presenting a missed opportunity for timely linkage to appropriate HIV prevention, care and treatment services.

Objective: To explore trends in, motivations for and barriers to couples’ HCT uptake among married or cohabiting individuals, and design, implement and evaluate a demand-creation intervention to increase couples’ HCT uptake among married or cohabiting individuals with no previous couples’ HCT experience.

Methods: This was a cohort study that used a mixed-methods approach; that is, both qualitative and quantitative methods of data collection were utilized. The study was conducted among married or cohabiting individuals and selected key informants in Rakai district, south-western Uganda. Four sub- studies (I-IV) were conducted between February 2013 and April 2015. Sub-study I was a secondary analysis of data to assess trends in HCT uptake (between 2003 and 2009) among 11,268 married or cohabiting individuals who contributed a total of 21,798 observations. Sub-study II was a qualitative study (August – October 2013) that used focus group discussions (18), key informant interviews (9) and in-depth interviews (6) to assess motivations for and barriers to couples’ HCT uptake among married or cohabiting individuals. Sub-study III was a cross-sectional study (November 2013 – February 2014) conducted to assess correlates of previous couples’ HCT uptake among 2,135 married or cohabiting individuals in three HIV prevalence strata. Sub-study IV was an evaluation of a cluster-randomized, demand-creation intervention trial, implemented between February and September 2014, to increase uptake of couples’ HCT among 1,174 married or cohabiting individuals with no previous couples’ HCT experience. Manual and software-guided (Nvivo, version 9) thematic analyses were conducted for qualitative data analysis (sub-study II). Chi Square for trend was used to assess trends in prior HCT uptake while multinomial logistic regression was used to identify independent predictors of prior HCT uptake (sub-study I) among married or cohabiting individuals. Logistic regression was used to assess correlates of previous couples’ HCT uptake (sub-study III). Intention-to-treat analysis was conducted using mixed effects Poisson regression to assess the effect of the demand-creation intervention on couples’ HCT uptake in the intervention versus the comparison clusters (sub-study IV). All quantitative analyses were conducted using STATA 15 statistical software, version 14.1.

Results: Previous receipt of couples’ HCT remained low over the years, ranging from 25-28% between 2003 and 2009 (Paper I); this increased slightly to 42% (n=2,020) in 2013 (Paper III). Among those that had ever tested as a couple, motivations for couples’ HCT uptake included the need to know each other’s HIV status; the need to link to HIV care and/or identify a medicine companion (if HIV-positive); and the need to reduce mistrust between partners. Among those that had never tested as a couple, barriers to couples’ HCT uptake included fear of receiving HIV-positive or HIV-discordant results, fear that couples’ HCT could reveal hidden infidelity, mistrust between partners, and fear of violence or marital disruption following couples’ HCT (Paper II). Prior HIV testing (adjusted Relative Risk Ratio=1.81; 95% Confidence Interval (CI): 1.32-2.50) (Paper I) and awareness about the availability of couples’ HCT services in the community (AOR=7.58, 95%CI: 5.63-10.20) (Paper III) were significant correlates for previous couples’ HCT uptake. Couples’ HCT uptake was 43% higher in the intervention than in the comparison clusters (20.3% versus 13.7%; adjusted Prevalence Ratio [APR] = 1.43, 95%CI: 1.02-2.01, P=0.04) (Paper IV). Being male (APR=1.41, 95%CI: 1.00-1.98), condom use in the past year (APR=1.87, 95%CI: 1.25-2.79) and mutual HIV status disclosure at baseline (APR=1.99, 95%CI: 1.36-2.91) were associated with increased odds of receiving couples’ HCT during the intervention period (Paper IV).

Conclusion: Study findings show that couples’ HCT can be increased through targeted demand-creation interventions, calling for a need to implement aggressive demand-creation interventions to reach a greater majority of married or cohabiting individuals that still do not know each other’s HIV status.