Memoire Online - Knowledge and perception on HIV premarital counseling and testing among unmarried young people of Kintampo town in the republic of Ghana,

Since demographic characteristics of respondents show a very heterogeneous and representative picture of the main social groups living in the District, we believe findings in this study are quite representative of the district. We can therefore surely discuss them.

Results from Table 3 showed that 66% of respondents have had premarital sex, with the mean age at first sex of 18 years (18.125 for females and 18.075 for males). Female were significantly 2.97 times more engaged in premarital sex than males (p=0.004116). These findings show a higher level of premarital sex as compared to those found in the 2003 GDHS where it was found that by age 18, almost half of women (48%) and one-fourth of men (25%) have had sexual intercourse⁵³. Findings from this study showing that men slightly engage early in sexual intercourse are in contradiction with the same 2003 GDHS where it was seen that it was rather women who early engage in sex (median age at 18.2 years) than men (median age at 20.2 years)⁵³. The vulnerability of women to premarital sex may be likely due to gender differences which are culturally favored. These cultural deviations which include coercive sex, rape, defilement etc, promote the transmission of HIV/AIDS and endanger the lives of women through involvement in unprotected sex with multiples partners⁵⁹.

Our findings are similar to those found in China where most newly weds in China have had sex before they marry.⁵⁹

Given the fact that premarital sex was also mentioned as a core barrier to HIV PCT from participants in IDI and FGDs, since those who have had sex tend to fear to go for test because they fear they might have been HIV infected, we think reduction of premarital sex among young unmarried adults would help to promote HIV PCT in the area. A certain number of measures, such as sex education, school-based educational programs, adolescent counseling, creation of virgin clubs, parents implication in sex education, reduction of poverty and illiteracy, interdiction of projections of pornographic film...among others, could help, as it has proved success Worldwide^{9,39,59,60,61}.

Findings in Tables 4 ,5, 6 and 7 and in Figures 5,6 and 7 support that 97% of respondents had good knowledge with 100% scoring positive perception towards HIV PCT, with little variation of knowledge and perception among both men and women. This is an encouraging picture on which District Health Authorities can rely to quickly implement a HIV PCT service in order to respond to their need. Since score of knowledge showed lower scores among 3% of respondents, education on HIV PCT should still be scaled-up continuously so that all unmarried young adults and growing adolescents in the District all acquire adequate knowledge on HIV PCT.

Although majority of respondents scored higher marks showing adequate knowledge on HIV PCT and confirming near universal awareness on HIV/AIDS revealed in the 2003 GDHS ^29,53, lack of knowledge emerged from each of the indicators in Table 4 in both sexes. In fact none of the indicators performed 100% of respondents giving right answers. For example it is noticeable that 10.3% did not know that children could be born HIV infected from their mothers, figure which is quite similar to data from the 2003 GDHS⁵³. Worse still, 38.7 % did not know that not all sexual unions and marriages are safe and good for health of both partners and offspring. And as a divergence, although showing big lack of knowledge in knowing diseases making unsafe sexual unions and marriages, almost 95% of respondents recognized they would consider health status as a core criteria when they will choose their marriage partners. All these show there is a deplorable big gap since such basic knowledge is actually the one which would help them perceive well the importance of HIV PCT.

Beside that, 82.7% said they would assess health status of their marriage partner through premarital examinations. This specific observation of high level of knowledge concerning the necessity of assessing good health status of their marriage partners and the ways to assess it, explains very well the near universal positive perception they showed towards HIV PCT (Table 6, 7 and figure 7).

It should be noted that majority of respondents (58%) showed big lack of knowledge about knowing a young adult who suffers or suffered from or died of HIV/AIDS, trend which is similar to figures from the 2003 GDHS⁵³. Also majority (63%) did not know anyone or any couple who underwent HIV PCT before marriage. The first observation does not imply young adults are not having HIV/AIDS or dying from it, when we know that in Ghana more than 90% of AIDS cases are found among adults aged 15-49%, the peak ages being 25-34 for females and 30-39 for males.²⁹This fact rather shows that education and awareness creation on HIV/AIDS is still lacking in some social groups. In fact many are those dying of HIV/AIDS and yet people around them don't just know it is AIDS or they think it is just something else. Promotion of peer education, including persons living with AIDS is crucial to break up this kind of gap of knowledge on HIV/AIDS ravages.

For the second observation we agree it is possible a respondent has not known yet someone or a couple who underwent HIV PCT before marriage. This may be true since HIV PCT is not yet formally implemented in Kintampo District. The service is still at an embryonic stage where only few would-be couples go and test. And even then because the HIV PCT is surrounded by a strict rule of secrecy, it may be even possible a person or couple the respondent knows did the test before marriage, but that he/she could not just inform others for confidentiality purposes. But since we know it is by observing other person doing good things that respondent could also consider that behavior as being good and finally adopt it him/herself⁶², we think at this stage not performing HIV PCT would remain a barrier to promote the HIV PCT behavior. Also people should not confuse confidentiality on HIV test results with confidentiality on practicing or attending HIV PCT. The first can be kept confidential while the second information can be made available to relatives and to peers. There is still much to do to first implement officially the HIV PCT centres where would-be couples can go for test and let people around know that the HIV PCT health practice (behavior) is being undertaken by others.

Surprisingly, although HIV PCT is a specific type of VCT, majority of respondents (84.7%) had heard more about HIV PCT than VCT itself (72%). This shows how education and awareness creation is still low or inconsistent on VCT and that even when respondents get the information they only get it partially, inadequately and incompletely. This could be confirmed by their sources of information about VCT and HIV PCT. Although majority of respondents heard about HIV PCT through audiovisual media channels (Radio, TV, Cinema or Video...) [78.5%], churches/Mosques [36.1%] and friends/third person [33%], it is surprisingly deplorable that only 31.9% heard about it through health workers who yet should have been the very top source of information if we only want the right information on HIV PCT to reach young people. Only few respondents (14%) heard about HIV PCT from their parents, meaning young adults rely on outside sources as their parents are more likely not to inform and educate them about HIV PCT and other sexual matters. Also likely it is possible these young adults get more information on HIV PCT compared with parents. This opposes and questions the workability of one of the strategies for the implementation of BCC and IEC programmes of addressing HIV/AIDS in Ghana, where parents are supposed to be educated to be positive role models for their children and also to play an active role in educating them about sexuality and other reproductive health related matters^9,61. Mass media seemed to be playing its role in the implementation of BCC and support towards an effective HIV PCT awareness, behavioral change, care and coping strategies as it is recommended in the National HIV/AIDS and STI Policy⁶¹. However the involvement of schools in informing young people about HIV PCT seemed still very low (29.2%).

It is worthy to note that the inexistence of effective drug to cure HIV/AIDS was known by majority of respondents (94.7%). This is a good point since from this we hope they could then deduce that the only available effective way to fight HIV/AIDS is its prevention which is considered central to the National effort to reduce the spread of HIV/AIDS in Ghana.⁶¹As a result, knowing HIV/AIDS does not have any effective drug to kill the HIV would definitely help them understand the importance of HIV premarital counseling and testing, one of usual preventive measures in the national framework to fight HIV/AIDS.

With reference to pictures 4 and 5 showing the routine reality that traditional herbalists in Kintampo District are having people living with AIDS (PLWAs) who come to them for treatment, it is important to attract your attention that such false claims of cure for HIV/AIDS negatively affects BCC in Kintampo. During one FGD one woman said the following quote:

It is true such claims of cure for HIV/AIDS may affect negatively compliance and patronization of preventive services such as HIV PCT in Kintampo. Therefore we suggest that the DHMT assist and orient those traditional herbalists as it is recommended in the National HIV/AIDS policy.⁶¹

Using the tri-polar scoring scale described earlier on, we found out that majority (97%) of respondents proved Good knowledge, with 41.3% scoring «Adequate Good Knowledge» versus 55.7% scoring «Average Good Knowledge», versus a minority (3%) proving Poor knowledge on HIV PCT. These results clarify one of the factors (poor public knowledge on HIV PCT) that we mentioned in our conceptual frame work (see Introduction) and wanted to verify in this study. The findings are sufficiently encouraging in the sense that, with this higher level of knowledge revealed contrarily to what we thought initially, they suggest there is a hopeful starting point from which the District can take off in implementing such service.

However it should be noted that when analyzing level of knowledge in different professional groups (Table 5), only traders scored adequate good knowledge while students and others scored average good knowledge. This is a surprise since we would normally expect students to know more than traders and other professional groups. But all the same, wherever you are or whatever you do, you may get or may not get access to the right information needed. Just to say that awareness creation on HIV/AIDS prevention should be scaled-up at all levels to ensure equitable accessibility of people to information.⁶¹

Also although the level of knowledge showed average good knowledge in all religious groups, Christian respondents scored the highest mean score ( 15.9[SD=2.9]) than Moslem and respondents with no religion. This confirms the observation we got in the field through IDI and FGD where it was shown that Christian religious institutions have started doing some educational activities on HIV PCT among their churchgoers and even some had started sending would-be couples for HIV PCT at the KDH, whereas it was not yet the case in Islam communities. Although not significant, this disparity of level of knowledge among respondents of different religious groups demonstrates that not all religion bodies have responded to the government advocacy for an effective national response to the problem of HIV/AIDS⁶¹.

It should also be noted that respondents of Akan ethnic group were more knowledgeable (adequate good knowledge) than their counterparts from other ethnic groups who scored average good knowledge. We think this may suggest that the Akan respondents have high access to HIV PCT information than others, without being sure from which kind of sources of information. A further study is needed to deeply research into this to determine the why of this discrepancy.

In figure 6, we also surprisingly noted that respondents from rural parts actually knew slightly more about HIV PCT than those coming from urban area although there was no significant difference. This discrepancy is difficult to explain although we may just relate it to differences in accessibility to or in response of attendance to opportunities of information between the 2 groups. This unexpected finding also tells how seriously people who live in rural areas take in IEC/BCC messages compared to those in urban areas.

The higher level of knowledge on HIV PCT among respondents from Kintampo District may prove somehow how active and effective has been the comprehensive BCC strategy addressing HIV/AIDS in Ghana and in Kintampo District to provide information guided by individual needs and perceptions.^30,31,61.

Indicators of perception of respondents towards HIV PCT showed encouraging results ranking from 80.7% to 100% (Table 6).

In fact results showed high risk perception to HIV (93.3%) [far higher than figures reporting low risk perception in Ghana²⁹], higher perceived severity of HIV/AIDS (100%), higher perceived threat of contracting HIV in case one marries without attending HIV PCT (98%), higher perceived benefit of HIV PCT (100%), high perceived self efficacy towards HIV PCT action (98%), high perception of HIV PCT as a subjective-family norm (96%), high perception of HIV PCT as a subjective-peer norm (96%), high perception of HIV PCT as a social norm (98.7%), high perceived barriers to HIV PCT practice (80.7%) and high perceived need of HIV PCT services (99.3%) among respondents. These are all conducive factors which may have led most respondents to be more attracted by HIV PCT practice, looking both at the high rate of willingness (98%) they manifested to undergo HIV PCT and at the high readiness rate (96.7%) to know and accept their HIV test results after a PCT session, contrary to what we initially presumed in the conceptual framework. In fact it is believed that people will take action to prevent, to screen for, or to control ill-health conditions 1) if they regard themselves as susceptible to the condition, 2) if they believe it would have potentially serious consequences on their health/life, 3) if they believe that a course of action available to them would be beneficial in reducing either susceptibility to or the severity of the condition, 4) if they are convinced that most people (family members, peers..) approve of the action (behavior), and 5) if they believe that anticipated barriers to (or costs of) taking the action are outweighed by its benefits⁶². Therefore the district authorities should orient the BCC strategies in specifically addressing those indicators so that HIV PCT is widely promoted in Kintampo district. Thus for behavior change communication strategies to succeed in fighting HIV/AIDS in new couples in the district, unmarried young adults must feel threatened by their current behavioral patterns (perceived susceptibility and severity) and believe that change of a specific kind of behavior (getting married after attending any PCT) will result in a valuated outcome (of protecting him/her and his offspring against HIV risk infection in attending HIV premarital screening) at acceptable cost. They also must feel themselves competent (self-efficacious) to overcome perceived barriers to adopt HIV PCT practice (behavior).

As you may have seen it in Table 5, majority of respondents (61%), recommended HIV PCT should be compulsory as opposed to minority (39%), saying it should rather be optional. Views of participants in qualitative study were even much divergent, constituting itself a discussion flow in view of the following quotes, just to mention a few.

«If we truly want to save lives, I think HIV PCT should be made compulsory, so that transmission of HIV will be reduced. Optional testing will still favor HIV spread in new couples since not all would-be couples will opt to go for it.»(IDI: District HIV/AIDS Response Initiative Coordinator /DA /GES/Kintampo, Picture No 12).

«No! In church matters, we don't make things compulsory, so HIV PCT should be made optional. The would-be couples have to decide what they want to do regarding their own life and health. We haven't reached the level where we ask for a medical certificate that indicates that you are HIV/AIDS free before celebrating your marriage. Our advice is that we talk to the would-be couples and each person him/her self has to accept the advice. If he/she decides to do the HIV test, fine. If not, well, we let them know that they will have to suffer the consequences.»(IDI: Rev.Pastor Methodist church/Kintampo)

«In church we leave to people their freedom to self acceptance and decision like God does for us. So HIV testing is not compulsory in our church before marriage. We only counsel would-be couples to do it. The last decision to test is for them»

(IDI: President of S^t Joseph Catholic church, /Kintampo, Picture No 13)

«Since most of young adults may not comply voluntarily, HIV PCT should be made compulsory. I believe in my Mosque as people like marriage it can still work very well like that»

(IDI: Imam/Central Mosque/Kintampo, Picture No 14)

«I think, the simplest better way is to make it compulsory. We were doing it in our church and it worked. But sometimes ago we received a letter from an NGO saying we should not continue to do it like that. But it has become a social normal behavior among my churchgoers. If I were to make a law, frankly it should be made compulsory»

(IDI: Rev Pastor, Pentecost's church/Kintampo)

«Yes. It should be compulsory in order to reduce the spread of HIV in new couples and families. This will bring happiness in the country»

(IDI: Traditional Herbalist/Ampoma )

«I am just not comfortable for HIV PCT to be compulsory. It should be optional rather. Eeeh!, I can't really explain why. Just make it optional. It is a stressful deal.»

(IDI: Private Medical Doctor/Kintampo)

«HIV PCT should be made compulsory. Because the rate at which HIV/AIDS is going high and higher in this place is terrible. Very soon within decades each family in Kintampo will have a HIV infected person or a HIV orphans/widows. So since couples don't come voluntarily, just scarce cases, it has to be compulsory.

(IDI: Matron Counselor/KDH, Picture No 15)

«Neither compulsory nor optional. Both are not good. If you make it compulsory, fine, but people will feel infringed in their right. If you make it optional, also fine. But some people will not do the test and the disease will still spread and decimate people. We should rather educate and encourage people so that HIV PCT becomes an individual, ,familial , social and routine norm of life so that we do It just spontaneously like we eat or put our dresses»

(IDI: Laboratory Technician/KDH)

«It should be compulsory. Parents should make sure that PCT is done before they give their children for marriage»

(A 34- year- old mother: FGD Traditionalist mothers/Ampoma)

«It should be compulsory because nobody likes the illness»

(A 45-year- old father: FGD Moslem fathers)

«Yes! It has to be compulsory. In our church it is organized by the marriage committee»

(A 64- year- old father: FGD Christian parents).

«It should be made compulsory. If not many people will not test. If you can accept to marry an HIV infected partner, fine, then it can be optional. But if you know you could regret it later, the best solution is to make it compulsory, what else? »

(A 23-year- old single girl: FGD Moslem girls, Picture No 16)

«It should be compulsory. But even so, people will still don't go for test, unless the government sets a strong conducive law on premarital tests, which will first force people to do It before realizing later it has become part of personal and social spontaneity.»

(A 24-year- old single boy: FGD young adults, Picture No 17).

Can we still discuss this issue after this discussion flow? If you look at it critically, what is obvious is that although views diverged, majority if not all respondents and participants are saying it should be compulsory. But what would the policy maker choose? If you are still free of HIV/AIDS, what is the option which secures you the best? If you are a PLWA, which option fits the best? And if you are PLWA children innocent victims from mother-to-child transmission of HIV, what would have been the option to protect you? And if you are a lawyer or a medical doctor or a religion leader, what is the best solution? If you are demographer planning for a future bright generation what is the best solution? We could still lengthen the list of similar questions, just to show that the view of each person depends on his/her own interest. The legislator should put all views together in order to make a holistic representative and acceptable policy that protect each individual and the community.

This issue on compulsoriness of HIV PCT always creates polemic among people. This is the case even among WHO/UNAIDS staffs ⁶³. But from public health point of view, disease screening is one of the most basic tools of modern public health and preventive medicine.⁶⁴

Although screening programs are commonly thought of as either voluntary (optional) or mandatory, there is in fact a continuum of approaches that can be taken. Faden and colleagues (1991) characterize five types of screening programs under which HIV PCT could fall: (1) completely mandatory, (2) conditionally mandatory, (3) routine without notification, (4) routine with notification, and (5) non-directive patient choice.⁶⁴

In a completely mandatory program, a government agency requires citizens to undergo a screening test and sanctions those who do not comply. So for instance in our case study, individuals who would marry without performing the test or pastors, bishops or Imam who would celebrate a marriage when a couple did not perform any test would be sanctioned. ⁶⁴

In a conditionally mandatory program, either government or a private institution makes access to a designated service or opportunity contingent upon participation in the screening program⁶⁴. For instance, medical authorities-legislators-lawyers and religion leaders could require would-be couples to undergo HIV PCT as a condition of receiving prenuptial certificate that would allow them to marry. And this is actually what we meant in asking the question whether HIV PCT should be compulsory or not and we believe majority of respondents who opted for the compulsoriness understood this.

In a non-directive patient choice program (voluntary testing) individuals are provided information about the test, and the choice about whether to be tested is left to them. Patients actively must choose to be tested, and if they do not opt to be tested, the default is that no testing will occur. This type of program is the model typically employed in the context of genetic counseling where it is labeled "non-directive counseling." This also is the model used by HIV anonymous test sites, including HIV PCT⁶⁴.

As the epidemic continues to affect people living in poverty and people who have historically been disenfranchised, there is an increased risk that testing can and will be used to discriminate against people infected with, or even thought to be infected with, HIV and will further isolate people with AIDS⁶⁴. Some of quotes got from some participants in FGDs went even far beyond all type of acceptable discrimination. Just reread this horrible quote:

If respondents understood compulsory HIV PCT like this, then it could not work. Thus, policy decisions must incorporate strong protections for those who are already suffering from discrimination⁶⁴.

It is true VCT and HIV PCT have helped to control HIV/AIDS and to target treatment for infected persons in a number of countries, such as Uganda¹⁰. This illustrates the tangible public health benefits of such screening efforts and explains why some countries have made HIV PCT mandatory rather than optional^10,42. Thus, if HIV PCT programs are poorly conceived, organized, or implemented, they may lead to interventions of questionable merit and enhance the vulnerability of groups and individuals⁶⁴.

There is the need of still studying further as to whether compulsory HIV PCT would work or not in the Kintampo District context. Despite the view of majority of respondents suggesting HIV PCT should be compulsory, District Health authorities should study the feasibility of this approach, knowing that optional (voluntary) approach has also failed in some VCT centres still not or feebly patronized in the country³⁶. Either it starts under the Voluntary (Optional) or mandatory approach, district authorities should put in place long term education and sensitization campaign to make sure HIV PCT later becomes a spontaneous «routine screening» with the full and straight commitment and understanding of communities and the target groups.

District authorities should also be aware that it has been found that when shifting from a type of approach to another, patronization of HIV PCT is always affected in the way that the number of clients patronizing premarital service tends to decrease when the examination become optional than when it was compulsory and to increase when PCT examination is free. The same study has shown a low rate of voluntary compliance to premarital examination because of fear of the results.¹³They should also examine the cost-effectiveness of a HIV mandatory premarital screening program based on current studies ⁶⁵.

If the approach of compulsory HIV PCT is chosen in Kintampo District, a cost-effectiveness study should also be planned in order to compare the cost with the effectiveness of such program. Also if optional HIV PCT program is to be implemented in accordance with the current National HIV/AIDS and STI Policy⁶¹, then Kintampo district authorities should realize they are putting in place a system against the views of the majority of the target group interviewed in this study.

Finally, experience of Uganda with a higher HIV prevalence rate showed that lack of non-committal in HIV PCT leaves room for being optional. And this led some religious groups and parents to make testing for HIV before marriage mandatory, although the Uganda policy supports it should be rather optional⁶⁶.

Findings from Table 7 and Figures 5 and 7 showed that the entire totality (100%) of respondents in both sexes had «adequate positive perception» towards HIV PCT irrespective of their different socio-demographic background. This clarifies with disagreement one of the factors (bad perception towards HIV PCT) in our initial problem analysis diagram. Despite Table 8 showed there was a significant weak positive linear relationship between level of knowledge and perception towards HIV PCT (p-value 0.007), meaning the score of perception slightly increases as the score of knowledge increases, it was observed however that even respondents with poor score of knowledge also had higher score of perception. This means little or average knowledge on HIV PCT is enough to still create a very strong positive perception towards HIV PCT among unmarried young adults. This is a proof that little or average knowledge could still result in generating positive perception towards a given behavior⁶².The similarities in score of perception among respondents of low and high score of knowledge underpins the fact that if we want to raise perception of people towards HIV PCT practice, we only need to simply create awareness on few important issues on don'ts and not necessarily bringing sophisticated scientific matters to them. Therefore the development of BCC and IEC materials and messages aimed at promoting HIV PCT should be based on participatory methods and research evidence-based data, leading to the production of appropriate messages and materials for different target groups according to their need of knowledge to fill appropriate identified gaps⁶¹.

As a comparison, our results showing adequate positive perception of unmarried young adults towards HIV PCT are quite similar to findings in Egypt where ESHRA and Colleagues found that most respondents from Menofia Governorate, except unmarried males, had a favorable perception towards HIV PCT⁵⁰.

Perception of the need of HIV PCT service was inversely (negatively) associated with Urban residence, to the fact of having had premarital sex and score of knowledge (Table 9).

In fact respondents from urban area were 5 times less likely to perceive the need of the PCT service than respondents from rural settlements. This is contrary to what have been reported in a similar study among Malawians⁴⁵.This may be due to the fact that young people from Urban areas may take all things for granted to the point of thinking all their health need will be automatically satisfied in life irrespective of their own expression.

Also respondents who have ever had sex were 16 times less likely to perceive the need of the service than still virgin respondents. This may be explained by the fact that for those who know they have engaged in risky premarital sex, fear to know their HIV serologic status may be higher and worrisome to the extent of leading them not even to perceive the need of such service¹⁰. It even joins the view of some participants in one of the FGDS.

Therefore promotion of sexual abstinence and of virginity through appropriate sex education and establishment of virgin clubs could help ensure that target groups express and understand the need of such services as it has been proved in Uganda and Zambia¹⁰. Also education and comprehensive counseling of those who happen to have had premarital sex should be carried out in order to dissipate the fear those respondents feel.

It was also found that increased score of knowledge on HIV/PCT was associated with decreased likelihood of the respondent to express the need of such service. So the higher the score of knowledge (the more knowledgeable a respondent), the lower the likelihood to perceive the need of HIV PCT service. This is contrary to our expectations but somehow compares with results from Malawi where it was found that respondents who had knowledge of sexually transmitted diseases (STDs), knowledge of HIV testing place were less likely to desire testing prior to marriage.⁴⁵We can't truly explain why it happens this way but we could say that it is possible that more knowledgeable people may take their health for granted because of their pride. Also it could be because it has been shown that although young people have a high level of knowledge about HIV/AIDS, the internalization or conceptualization of their own potential risk is very low¹⁰. Also according to our findings, it seems that knowledge would lead to fear of HIV-testing or a sense of non-vulnerability, such that the need for HIV testing may not be appreciated by the knowledgeable respondent.

On the other hand, perception of the need of HIV PCT service was positively associated with older age, females, Christian religion, Akan and Mo ethnic groups, post-primary educational level, Students and level of perception towards HIV PCT.

Increased age seemed to increase gradually the likelihood for the respondents to perceive the need of HIV PCT. This may be due to the fact that as children grow up they start thinking of the formation of their own family through marriage. Therefore while seeking for and gathering information needed on marriage they may hear about and understand the need of such service.

Females were 19.5 times more likely to perceive the need of such service than males. This may be justified by the fact that females even proved slightly higher mean scores of knowledge (15.76 versus 15.68) and of perception (21.8 versus 21.7) than males. It may also be explained by the fact that generally females are more flexible and easy to be convinced than males who are mostly naturally less flexible. Our findings are in some disagreement with findings from «The Adolescent Counseling and Recreation Centre (AcRC)» in Kenya and « the Center Dushishoze» , a youth center in Butare /Rwanda, where it was rather found that more males were expressing VCT need than female clients¹⁰.

Christian respondents were 5.57 times more likely to perceive the need of HIV/PCT service than non Christian ones. This stands true because as said earlier on, most Christian religions have started educating and sensitizing their young adults towards HIV PCT.

Respondents belonging to Akan and Mo Ethnic groups were 2.8 times more likely to perceive the need of HIV/PCT service than respondents from other Ethnic groups. This could be explained by the fact that Akan and Mo showed higher scores of knowledge than respondents from other ethnic backgrounds.

Respondents of post-primary educational level were 4.13 times more likely to perceive the need of HIV/PCT service than respondents of lower educational level. This contradicts the above findings showing that score of knowledge was negatively associated with perceived need of the service. But it confirms that somehow increased level of knowledge should be translated into behavior change so as to differentiate those still not adopting a positive behavior because of their ignorance. It also affirms that educational attainment may affect the individual's perceptions and thus indirectly influence health related behavior.⁶⁴ This explanation may also explain the fact that students were 4.097 times more likely to perceive the need of HIV/PCT service than respondents of other professional categories.

Finally increased level of perception towards HIV/PCT increases by 4.47 times the likelihood for a respondent to perceive the need of the service than a respondent with lower score of perception. So the higher the score of perception the higher the likelihood to perceive the need of HIV PCT service. This stands far true since it is the individual's perceptions towards an illness or an available treatment or behavior which will lead the individual valuing the benefit of the action so that he/she can adopt the behavior to protect him/her to the disease he/she perceived as very dangerous⁶⁴.

5.4. FACTORS INFLUENCING WILLINGNESS TO UNDERGO HIV PCT

Table 10 showed that we could strongly predict the willingness of a respondent to undergo HIV PCT from his/her readiness to know and accept his/her HIV result (p<0.001). Therefore the more the respondent says he /she will be ready to know and accept his/her HIV test result, the higher the likelihood of the willingness to attend HIV PCT. This meets findings found in Thailand in a cluster randomized trial used to assess the effect of an active group intervention in promoting utilization of voluntary HIV testing and counseling⁶⁷. In fact since it is reported that most people fear to know their HIV serologic status¹⁰, it is definitely obvious that an individual who has coped with this fear will more likely intend to do the test now as he/she feels ready to know and accept his/her HIV serologic status. Therefore if the service is to be implemented in Kintampo, many sessions of sensitization and anticipated pre-counseling among the target groups would be recommended in order to dissipate the anxiety and the fear clients manifest on the eventual HIV test results.

About other associations, not significant, it was noted that increased age were associated with low likelihood to intend undergoing HIV PCT. This finding is in agreement with findings in a study done in 1970 in Yonsei-Korea among Protestant Ministers on `Knowledge and attitude and practice about marriage...' where age was found to be the most important factor influencing the attitude of respondents towards PCT, the younger respondents showing more positive attitude than the older one. ⁵¹ However our result is inconsistent with explanations given above where increased age seemed associated with positive perception of HIV PCT service. Our finding is also inconsistent with findings from a study done in Malawi in 2004 which rather showed a significant, although weak, association between increasing age and supporting HIV-testing prior to marriage⁴⁵. It is possible that older respondents, who were probably already engaged in many unprotected sexual intercourses with multiples partners, could not support premarital HIV testing because of fear of the HIV test results. It is also possible the older groups, although more appreciative of the reality of HIV/AIDS and their support, think the test is rather for those still younger. Testimony from one old couple we interviewed seemed to support this feature.

Students and respondents of post-primary level all seemed less likely to intend undergoing HIV PCT than their counterparts of other professional categories. This is in some variance with our previous discussions concerning the positive association of the two parameters with the positive perception of the need of HIV PCT services.

Also respondents engaged in premarital sex were less likely to intend doing a HIV PCT than those still virgin. This confirms the above findings and stands true by the same explanations that those who have engaged in risky unprotected sex do not intend to perform the test because of fear of the HIV test result¹⁰. This is because most people think sexual intercourse is the only major route of transmission of the disease.

One would-be couple with premarital sex history who just benefited from premarital counseling sessions organized by their pastor in their local church in Kintampo consented to testify their experience through this work in order to teach it to others that HIV PCT is still feasible and helpful despite past sexual bad behaviors.

This live testimony strongly proves how counseling sessions should be promoted and carried out in Kintampo district in order to dissipate the fear of those unmarried young people who would fear to attend HIV PCT because of their premarital sex history.

It is not understandable that respondents who yet perceived the need for the HIV PCT services were now surprisingly less likely to intend doing the test than those who do not perceive its need at all. This is completely contradictory to our expectation and partially demonstrates how when dealing with HIV testing it is difficult to predict a respondent would concretize his/her own view in doing the HIV test because of so many parameters, especially the fear of the results¹⁰. Reason why long term pre-counseling sessions could help convince such respondents to finally intend doing the HIV test.

Individuals who perceived HIV PCT should be provided free of charge or at affordable cost were less likely to intend doing the test than others. This can easily be understood insofar as most people not willing to attend a heath service usually pretend they do not have money to do so even when they have it. On the other hand individuals who truly felt they were poor might have hesitated to manifest the willingness to undergo HIV PCT until later on, once the service will be implemented at free charge, they would may be now intend to do the test once they are sure it is free.

Individuals living in the urban areas were 3.1 times more likely than rural dwellers to accept voluntary HIV counseling and testing prior to marriage. This is similar to results found in Malawi⁴⁵but enters in contradiction with previous observations showing young people from rural parts perceived more than those from urban areas the need of the implementation of HIV PCT service. Although we cannot determine the reasons for this difference on the basis of the current study, this inequality has far-reaching public health implications because over 80% of unmarried young adults live in rural areas in the district. Further studies are needed to explore this discrepancy.

Akan and Mo respondents were 2.5 times more likely to intend undergoing HIV PCT than respondents from other Ethnic groups. As said earlier on, this may be due to the fact that they also proved high level of knowledge on HIV PCT than others. If we consider the fact that Akan and Mo are the most populous Ethnic groups in the 3 sub-Districts involved in this study and in the whole district, we could assume at this stage that there is hope that such service, if implemented, would be patronized much by Akan and Mo respondents, whether this is true or not.

Christians were 3.6 times more likely to intend undergoing HIV PCT than respondents of others religion groups. This stands true using the same explanations mentioned earlier on.

Female respondents were 3.6 times more likely to intend undergoing HIV PCT than males. This joins findings from Uganda but contradicts some findings from Kenya and Rwanda.¹⁰

Increased score (level) of knowledge and of perception were positively associated with willingness to undergo HIV PCT. This meets our expectations because we believe knowledge empowers people to act positively. However our finding contradicts findings from Malawi.⁴⁵ In fact as people perish by ignorance, it is a good thing that knowledge, once acquired, could help people to adopt positive behaviour than before they got that knowledge.⁶⁴ This could also be translated into positive perception so that those with positive perception show much interest in intending undergoing HIV PCT than those with negative or low perception of it.

Finally, respondents expressing the high need of confidentiality were 2.6 times more likely to intend doing the testing than those who do not. This finding espouses results from a similar study among Malawians, where Humphreys Misiri and Adamson S. Muula found that those who preferred maintenance of confidentiality if one is HIV positive were more likely to accept HIV testing prior to marriage⁴⁵. This feature corresponds to the views of most participants in IDI and FGDs who recognized lack of confidentiality as a major barrier and suggested consequently maintenance and guarantee of confidentiality as a core way to promote the service and make it acceptable and attractive for people (see up-coming point 5.7.4).

It should be noted through Table 11 that about 86% of respondents had paired higher probability (>0.75) of perceiving the need of HIV PCT service in Kintampo and of willingness to undergo HIV PCT. Assuming this picture stands true for the whole target population in Kintampo District, we could be self-confident based on this study that once the service is implemented, majority (at least 86%) of young people would definitely patronize it. On the other hand this suggests that not implementing or not promoting HIV PCT would definitely result in low patronization of the VCT service as initially presumed in our conceptual framework. This could serve as a motivator for district authorities to plan for such service as soon as possible.

Knowledge and perception on HIV premarital counseling and testing among unmarried young people of Kintampo town in the republic of Ghana,

Chapter Five

DISCUSSIONS

5.4. FACTORS INFLUENCING WILLINGNESS TO UNDERGO HIV PCT