Journal of Rural and Tropical Public Health 36

ORIGINAL RESEARCH

UTILIZATION OF VOLUNTARY COUNSELLING AND TESTING SERVICES BY WOMEN IN A KENYAN

VILLAGE
MARGARET MUGO1, CHARLES KIBACHIO2, and JOHN NJUGUNA2

1Constituency Aids Control Coordinator, Laikipia West, Nyahururu; and 2District Public Health Office, Nyandarua, Kenya.

Corresponding Author: Mr John Njuguna ([email protected])

ABSTRACT

Background: Voluntary HIV Counseling and Testing (VCT) is a key intervention in HIV/AIDS prevention as it serves as an entry
point for other key interventions like antiretroviral therapy. Methods: A cross-sectional descriptive study was carried out among 138
women of reproductive age in a Kenyan village to determine their perceptions and utilization of VCT services. Results: The mean
age of participating women was 30.1 years and 74.6% (95%-confidence interval (CI) 66.5 to 81.7) had visited a VCT centre. The key
hindrances to women to use VCT services were stigma (38.4%), fear of the unknown (37.7%) and fear of rejection (10.9%). Women
in the 15 to 24 year age group were more likely to have visited a VCT centre compared to those in the 25 to 49 age group (Odds-
ratio = 2.2; 95% CI 0.95 to 5.3). A majority of respondents (88.4%) stated that those living with HIV/AIDS in their community were
stigmatized. Conclusion: The study showed that there was a need to engage the community to reduce HIV/AIDS related stigma.
Although use of VCT services was already relatively high amongst young women future efforts to increase uptake of services in this
sexually active group might be required. These efforts could entail establishing youth friendly VCT services and youth lay
counselors.

KEYWORDS: Voluntary counseling and testing; Kenya; HIV/AIDS; Africa.

SUBMITTED: 30 December 2009; ACCEPTED: 7 March 2010

INTRODUCTION conducted in Kenya and Tanzania estimated that the

hypothetical cost of VCT was comparable to the cost of
HIV/AIDS is a major public health problem in Kenya. In 2008 sexually transmitted infections (STI) services and childhood
the prevalence of HIV/AIDS in Kenya was 7.8% (UNAIDS, immunizations (Sweat 2000). In Kenya, the number of
2009). Women were more affected with HIV (8.7%) people who have been tested for HIV has increased from
compared to men (5.6%) (Nascop, 2008). In Kenya 1000 in 2000 to more than 2 million in 2007. This has been
Voluntary HIV Counseling and Testing (VCT) is the process partly attributed to an increase in the number of counseling
whereby an individual or a couple undergoes counseling to and testing sites from 3 in 2000 to close to 1000 in 2007
enable him/her/them to make an informed choice about (Republic of Kenya, 2008). Most of these VCT sites are
being tested for HIV. The decision for testing remains the client initiated and have certain shortcomings. Transport
choice of the individuals and the process is completely difficulties and fear of being sighted at a health facility may
confidential. However, VCT is more than drawing and limit the number of people being tested (Yoder, 2006).
testing blood and offering counseling sessions. It is a vital
point of entry to other HIV/AIDS services including In addition there are factors such as inadequately skilled
prevention and clinical management of HIV related illnesses, service providers and inadequate resources (Matovu, 2007)
control of tuberculosis, psychosocial and legal support, and which might hinder the utilization of VCT services. Also, the
prevention of mother to child transmission of HIV (Painter, stigma of HIV/AIDS, fear of negative reactions due to
2001; Sangiwa, 2000). disclosure of being positive, as well as the perception of
being at low risk for HIV infection might further restrict the
VCT can also be an effective behavior change intervention. use of VCT (Matovu 2007). Women were found to be
A meta-analysis of the effect of HIV counseling and testing particularly disadvantaged as utilization of VCT might
found that HIV positive individuals who used VCT reduced expose them to partner violence, and marriage dissolution.
their risk behaviours and had safe sex more frequently In addition their lack of autonomy hinders women in Kenya
(Weinhardt 1999). Despite high initial costs, VCT has been to use VCT service, even when it is offered free of charge
shown to be a cost effective long-term strategy, suggesting (Pool 2001).
VCT to be a feasible public health intervention. A study
JRuralTropPublicHealth 2010, VOL 9, p. 36 ‐ 39 copyright
Published by the Anton Breinl Centre of Public Health and Tropical Medicine, James Cook University
 Journal of Rural and Tropical Public Health 37

HIV disproportionately affects women in Kenya, with an was undertaken during the months of April to May 2008.
estimated 1.8 women infected for every man (Republic of Data was analyzed using SPSS version 11 (SPSS Inc,
Kenya, 2004). Despite the increased uptake of VCT Chicago, Illinois).
services, nearly two thirds of Kenyans did not know their
HIV status, and four out every five HIV positive Kenyans did
not know that they were infected (Nascop, 2008). The RESULTS
present study looked at the utilization of VCT services
among women in a Kenyan village. All participating women were Christians and had a mean
age of 30.1 years. Almost all (98.6%) of them had heard of
HIV/AIDS. The source of information was mostly from the
METHODS radio (44.9%) and the hospital (27.5%). When asked if a
woman can transmit the virus to members of her household,
The study area was Maina village which is located in 81.2% of respondents said “yes”. Women responded that
Laikipia West district of the Rift Valley province of Kenya. transmission can be through blood (77.5%), shaking hands
The district lies on the leeward side of Mt Kenya. It has an (0.7%) and eating together (0.7%).
annual average rainfall of approximately 700 mm and the
area is categorized as semi arid. Communities here Counseling was cited as the key service offered in a VCT
comprise of subsistence farmers growing crops, mainly center by 73.2% of respondents. VCT was defined as
maize and beans, and keeping livestock. Maina village counseling and testing of HIV by 88.4% of participants. A
(population about 25,000) was started in 1965 to settle majority of respondents (63%) had learnt about VCT through
people who had been employed in the settler farms and the radio and 10% through television. When asked where
government service (UN Habitat, 2008). Maina village is VCT services were offered in their locality a majority
bisected by a main road. A government run dispensary mentioned the health center (54.3%) and dispensary (29%).
provides health care including VCT services. There is also A majority (72%) reported that the distance to the local VCT
an administrative post, a number of schools and churches. provider was less than 5 km.
Maina village is not a typical rural Kenyan village but rather
a peri-urban area, with residents being able to access VCT A majority of respondents (74.6%; 95%-confidence interval
services from a number of providers. The dispensary (CI) 66.5-81.7) had previously been to a VCT center. The
located centrally in the village offers VCT services. preferred services were counseling (68.8%) and health
Nyahururu town is less than five kilometers away and offers education (10.9%). The participants perceptions were that
another three VCT centers. women living with HIV/AIDS in the community were
stigmatized (61.6%), rejected by parents (8.0%), and
Study design divorced by husbands (4.3%.) The key hindrances to
women utilizing VCT were stigma (38.4%), fear of the
The study design was cross-sectional. The study population
unknown (37.7%) and fear of rejection (10.9%). When asked
comprised women of child bearing age between 15 to 49
to whom they would disclose test results, the respondents
years. Ethical clearance was obtained from the ethical
cited husbands (41.3%), partners (32.6%), and relatives
committee at the Kenya Medical Training College and from
(13.8%). A majority of respondents (88.4%) said that
the District Health Management Board, Laikipia district.
partners were being invited to join during VCT sessions.
The public health officer in charge of the village and the
The statistical analysis of predictors of VCT use showed no
local elders introduced the study to the community prior to
significant results. Women aged 15 to 24 years were twice
data collection. The same elders led the researcher and
as likely to report using VCT services compared to older
introduced her to the various homes during the actual data
women (OR 2.2; 95% CI 0.95-5.3). Women with secondary
collection phase. Most of the interviews were carried out in
level education or higher were more likely to report using
the privacy of homes and the languages used were English,
VCT compared to women with only primary level education
Swahili and Kikuyu. The latter is a local dialect.
(OR 1.3 95% CI 0.89-1.7). Married women were more likely
to report using VCT compared to unmarried, widowed or
Sampling was not random. Maina village is divided into four
divorced women (OR 1.2 95% CI 0.88-1.6).
areas and two relatively more densely populated areas were
allocated a proportionally higher sample size. Eligibility
criteria for participants were being female, aged 15 to 49
DISCUSSION
years, and having lived in the study area for more than six
months.
A high proportion of respondents of the present study
reported the use of VCT services, though the study did not
Consent was obtained verbally after the purpose of the
determine whether the responding women had used VCT for
study was explained to the women. A semi structured
testing for HIV/AIDS or counseling. A study from 2004 in the
questionnaire was administered, after informed consent had
neighboring district of Nakuru, found that 35.9% of
been received. The survey tool included general knowledge
respondents had been tested for HIV (Irungu 2008).
questions about HIV/AIDS; questions referring to the
Preliminary findings of the Kenya AIDS survey from 2007
availability of VCT services in the local area; the range of
indicated that about 43.3% of women aged 15 to 49 years
services offered; and to stigma related issues. The study
had been tested for HIV (Nascop 2008). In Kenya, it is
JRuralTropPublicHealth 2010, VOL 9, p. 36 ‐ 39 copyright
Published by the Anton Breinl Centre of Public Health and Tropical Medicine, James Cook University
 Journal of Rural and Tropical Public Health 38

estimated that approximately 50% of urban residents have ACKNOWLEDGEMENTS

been tested for HIV at least once, compared to 30% in rural
areas (Nascop 2008). We are grateful to the women of Maina village for
participating in the study.
The study area was the previous control site for a
community driven reproductive health program for young
people (Erulka, 2003). The final survey in 2001 showed that REFERENCES
21% of girls had sexual initiation and 30% had had more
than three sexual partners in the last three years. It is Erulka AS, Ettyang LI, Onoka C, Nyaga F, and Muyonga A
therefore likely that young women may have perceived (2003). Nyeri Youth Health Project: Impact of a Community-
themselves to be at risk of contracting HIV and may have driven Reproductive Health Programme for young people
used the VCT services of the area. There might be a need and community members in Kenya, Population council,
to expand access to VCT services for this group of clients Nairobi.
given the limitations of the facility based services (Matovu,
2007). Possible options should include starting youth Glynn J, Carael M, and Auvert B (2001) Why do young
friendly services and using lay counselors to provide women have a much higher prevalence of HIV than young
community based VCT services. HIV/AIDS related stigma men? A study in Kisumu, Kenya and Ndola, Zambia. AIDS;
was found to be a major impediment to utilization of VCT 15 (Suppl 4): S51-S60.
services. Strategies must be put in place to reduce stigma, if
the uptake of VCT services is to be increased. Irungu TK, Varkey P, Cha S, and Patterson.J.M (2008). HIV
voluntary counseling and testing in Nakuru, Kenya: findings
Our study showed that younger women had a tendency from a community survey. HIV Medicine; 9:111-7.
although not statistically significant to reporting VCT service
use more frequent. This result is encouraging as in Kenya, a Matovu JK, and Makumbi, FE (2007). Expanding access to
woman aged 15 to 24 years is estimated to be four times voluntary HIV counseling and testing in sub- Saharan Africa:
more likely to be HIV positive compared to a man in the alternative approaches for improving uptake, 2001-2007.
same age group (Nascop 2008). In the studied community, Tropical Medicine and International Health; 12: 1315-22.
young people comprised 27.1% of the population, 14%
being female. National AIDS and STI Control Programme (NASCOP)
(2008). Kenya AIDS Indicator Survey 2007, Preliminary
Marital status had also a slight but non-significant impact on Report, Ministry of Health, Nairobi.
utilization of VCT services. This is encouraging as marital
status is a risk factor for HIV infection (Glynn, 2001). Social Painter TM. (2001) Voluntary counseling and testing for
norms are more likely to accept sexual activity in marriage, couples: a high leverage intervention for HIV/AIDS
making a visit to the VCT centre less embarrassing. Women prevention in sub-Saharan Africa. Social Science and
who were widowed, single or separated tended to utilize Medicine; 53:1397-411.
VCT services less frequently. However, in Kenya women in
this group have a high HIV prevalence ranging between Pool R, Nyanzi S, and Whitworth J (2001). Attitudes to
17% and 21% (Nascop 2008). voluntary counseling and testing for HIV pregnant women in
rural south-west Uganda. AIDS Care; 13: 605-15.
Education also had a positive albeit non-significant impact
on the utilization of VCT. Studies have previously Republic of Kenya. Ministry of Planning and National
demonstrated an increase in VCT with increasing level of Development. (2004) Demographic and Health survey,
education (Wringe, 2008; Sherr, 2007). Arguably people Central Bureau of Statistics, Nairobi.
with higher level of education are in general more able to
access and comprehend health promotion campaigns. Republic of Kenya, National Aids Control Council, Office of
the President, Kenya (2008). UNGASS 2008 Country Report
Limitations of the study included a relatively small sample for Kenya, NACC, Nairobi.
size and the non-random sampling method used. There is
also a possibility of a Hawthorne effect. The respondents Sangiwa MG, van der Straten A, and Grinstead OA. (2000)
may have perceived that ideally they should have used the Clients’ perspective to the role of voluntary counseling and
VCT services. This might have led to an over-estimation of testing in HIV/AIDS prevention and care in Dar es Salaam,
the use of VCT, in particular, as VCT services had extensive Tanzania: The Voluntary Counseling and Testing Efficacy
coverage in the Kenyan mass media. In addition, some Study. AIDS Behaviour; 4, 35-48.
aspects of the study, such as the question “why women did
not use the services”, might have been better explored using Sherr L, Lopman B, Kakowa M, Dube S, Chawira G,
qualitative research methods. This may be an area of Nyamukapa, C, Oberzaucher N, Cremin I, and Gregson S
possible future studies. (2007). Voluntary counseling and testing: uptake, impact on
sexual behaviour; and HIV incidence in a rural Zimbabwean
cohort. AIDS; 21: 851-60.

JRuralTropPublicHealth 2010, VOL 9, p. 36 ‐ 39 copyright

Published by the Anton Breinl Centre of Public Health and Tropical Medicine, James Cook University
 Journal of Rural and Tropical Public Health 39

Sweat M, Gregorich S, Sangiwa G, Furlonge C, Balmer D, Weinhardt LS, Carey MP, Johnson BT, and Pickham NL.
Kamenga C, Grinstead O, and Coates T (2000). Cost (1999). Effects of HIV counseling and testing on sexual risk
effectiveness of voluntary HIV-1 counseling and testing in behavior: a meta-analytic review of published research,
reducing sexual transmission of HIV in Kenya and Tanzania. 1985-1997. American Journal of Public Health; 89:1397-
The Lancet; 356:113-21. 1405.

UNAIDS. AIDS epidemic update November 2009. W.H.O. Wringe A, Isingo R, Urasa M, Maiseli G, Manyall R,
UNAIDS/09.36E/JC1700E Changalucha J, Mngara J, Kalluvya S, and Zaba B (2008).
(http://data.unaids.org/pub/Report/2009/JC1700_Epi_Updat Uptake of HIV Voluntary and Counseling services in rural
e_2009_en.pdf) accessed March 2010. Tanzania: implications for effective HIV treatment and
equitable access to treatment. Tropical Medicine and
UN HABITAT (2008). Maina Village Community Water and International Health; 13(3):319-27.
Sanitation Project, Kenya. Cited November 2009
http://new.unhabitat.org/downloads/docs/2205_23468_Main Yoder PS, Katahoire AR, and Akol Z (2006). Home based
a.pdf HIV testing and counseling in a survey context in Uganda,
ORC Macro, Maryland.

JRuralTropPublicHealth 2010, VOL 9, p. 36 ‐ 39 copyright

Published by the Anton Breinl Centre of Public Health and Tropical Medicine, James Cook University