Willingness by people living with HIV/AIDS to utilize HIV services provided by Village Health team workers in Kalungu district, central Uganda

Background: Less than one quarter of people in need have access to HIV services in Uganda. This study assessed willingness of people living with HIV/AIDS (PLWHAs) to utilize HIV services provided by Village Health Teams (VHTs) in Kalungu district, central Uganda. Methods: A cross-sectional study conducted in two health facilities providing anti-retroviral therapy enrolled 312 PLWHAs. Pre-tested semi-structured questionnaires were administered to participants at household level. A forward fitting logistic regres sion model computed the predictors of willingness of PLWHAs to utilize services provided by VHTs. Results: Overall, 49% were willing to utilize HIV services provided by VHTs increasing to 75.6% if the VHT member was HIV positive. PLWHAs who resided in urban areas were more likely to utilize HIV services provided by VHTs (AOR 0.24, 95%CI 0.06-0.87). Barriers to utilizing HIV services provided by VHTs were: income level > 40 USD (AOR 6.43 95%CI 1.19-34.68), being a business person (AOR 8.71 95%CI 1.23-61.72), peasant (AOR 7.95 95%CI 1.37-46.19), lack of encouragement from: peers (AOR 6.33 95%CI 1.43-28.09), spouses (AOR 4.93 95%CI 1.23-19.82) and community leader (AOR 9.67 95%CI 3.35-27.92). Conclusion: Social support could improve willingness by PLWHAs to utilize HIV services provided by VHTs for increased access to HIV services by PLWHA.


Background
An estimated 33.3 million people are living with HIV globally, 67% of whom reside in sub-Saharan Africa. This region accounts for almost 70% of 1.7 million HIV-related deaths that occurred in 2011 1 . Uganda is one of the countries with an increasing number of People Living with HIV/AIDS (PLWHAs) partly due to new infections and longevity due to the widespread use of Anti-retroviral Therapy (ART) 2 . The increasing demand for HIV services in many African countries is currently hampered by health systems inadequacies leading to limited access to many patients in need. In order to address this, community health workers that exist in most countries have not only contributed to the improvement of Maternal, Newborn and Child health (MNCH) indicators but also to general HIV care and treatment especially in rural communities 3,4 . Organizations have engaged community health workers in counseling, home-basedcare, health education, adherence support and livelihood support for PLWHAs. Desirable outcomes of this include a reduction in the work load on health workers and also reduction in the waiting time for PLWHAs to access HIV services 5,6 .
Community health workers can therefore be used as a vehicle to increase access to HIV services in the context of increasing demand for such services with limited human resources for health to provide such services 7,8 . Task shifting in health care systems in many African countries has been used to offer quality, cost-effective care to more PLWHA than a physician-centeredmodel because it reduces the work load among the health workers offering HIV care and managemen t9, 10 . Engaging community health workers to offer basic HIV services to PLWHA is potentially one of the avenues to improve access to services consequently reducing work load among health workers and improving adherence to ART 7,8 .
Studies have shown that in a number of different settings there is no significant difference in the quality of care of patients who receive services from community health workers compared to those receiving health facility based care 5,[11][12][13] . In addition, there is no evidence to show if the PLWHAs are ready to utilize HIV services provided by community health workers of either sero-status. In Uganda, Kalungu is a district with one of the highest HIV prevalence rates in Uganda with only 20% of its population having access to HIV services and which would benefit from the use of community health workers in providing HIV services. Village Health Teams (VHTs) are made up of community members trained in basic health care skills. This study was therefore conducted to assess the willingness of PLWHAs in this district to utilize HIV services provided by community health workers, in the context of VHTs.

Study design
A cross-sectional study was conducted in two health facilities in Kalungu district. These were Bukulula Health Centre (HC) IV and Kalungu HCIII.

Study setting
Kalungu district has two admisitrative units or health sub-districts (HSDs) i.e. Kalungu East and Kalungu West. Kalungu has one HCIV and 19 HCIII's according to Uganda's Ministry of Health referral hierachy. All facilities at HCIII and IV level are antiretroviral treatment (ART) centres serving a population of 30,000 PLWHAs. Kalungu HCIII and Bukulula HCIV are the biggest ART centres in Kalungu with 10,000 and 20,000 registered PLWHA respectively. These two ART centers have a nurse-to-patient ratio of 1:300 with 100 VHTs covering 25 villages. The main role of village health teams is to sensitize and educate patients on general health services on a monthly basis. Bukulula HCIV has 1019 and 43 PLWHA on first and second line ART respectively while 49 are active clients on pre-ART care. Kalungu HCIII has 512 and 72 PLWHA on first and second line ART respectively while 29 are active clients on pre-ART care.
Regarding staffing levels, Bukulula HCIV has one medical offier and six enrolled nurses trained in HIV care and management. It has two peer counsellors who offer adherence counseliing to HIV positive patients and a dedicated laboratory with lab workers trained to conduct rapid diagnostic tests and CD4+ cell counting. On the other hand, Kalungu HCIII has only two clinicians and three nurses who offer HIV counseling, testing and treatment services. Blood samples are transported to Bukulula for CD4+ cell testing and to Kampala for viral load (VL) testing Sample size and enrolment of participants A modified Kish Leslie formula (1965) was used to estimate the sample size required 14 . A total of 290 respondents were computed using a 75% acceptance rate 15 , 95% confidence interval, a precision of 5%. A factor of 10% of the sample size was included to cater for non-response bringing the total sample size to 320.
Simple random sampling of registered HIV positive patients seeking care was conducted from each of the sites. Those who had not attended these facilities on three consecutive visits were excluded. Probability proportionate to size sampling was applied to determine the number of PLWHA to be selected for interviews at each ART sites.
Inclusion criteria included PLWHAs aged 18 years and above receiving HIV services in Bukulula HCIV and Kalungu HCIII while those who did not consent or too sick to participate were excluded.

Study measurements
Willingness by PLWHA to utilize HIV services offered by VHTs was a binary outcome variable categorized as a 'Yes' and 'No". Independent variables that were elicited from the participants included social demographic characteristics including information related to their ART orientation. Community factors like peer encouragement, partner/spouse encouragement and community leader encouragement were also measured as binary outcomes "Yes" for those who had been encouraged by peer, partner/spouse and community leader respective while "No" was coded for those who answered otherwise.

Data collection
Data was collected by use of pre-tested structured questionnaires that were administered by trained interviewers. These tools contained questions on the respondents' socio-demographic characteristics and other plausible and explanatory variables. Quantitative data was collected from April to May 2014. Tools with collected data were field edited by the principal investigator in order to ensure quality control by checking for missing fields among other checks.

Statistical analysis
Double data entry and cleaning of data was done in Epi info 3.5.1 which was then exported to STATA version 12.0 for statistical analysis. Descriptive statistics was conducted and presented using frequencies and percentages. A multi-variable logistic regression model was used to determine the association between independent factors and willingness of participants to utilize HIV services provid-ed by VHTs. Odds ratios with their corresponding 95% confidence intervals were presented. In all analyses, a p< 0.05 was considered statistically significant.

Ethical considerations
Ethical approval to conduct this study was obtained from the Uganda National Council for Science and Technology in April 2014. Privacy and confidentiality of respondent information was upheld by the research team. Informed consent was sought and obtained from all respondents before conducting any interview. Respondent anonymity was observed through use of questionnaire identification numbers. Permission to carry out this study in Kalungu district was obtained from Kalungu district administration.

Socio-demographic characteristics of study participants
A total of 320 participants were recruited in the study, however 9 were dropped from the analysis because they did not complete the interviews. Overall, 49% (43.43-56.42) of the study participants were willing to utilize HIV services provided by VHTs. This proportion increased to 75.6% (70.76-80.36) if the VHT member was HIV positive (Table 1). Of the respondents willing to utilize HIV services provided by VHTs 33.1% of them were aged 41-60 years (mean age 31.76 and standard deviation of 9.30), 73% were female, 50% were married, 95% were Roman catholic, 73% had completed primary level education, 70% were resident in urban areas, 69.8% were peasants living on less than one USD per day (75.5%). Majority of the respondents (91.1%) had spent more than one year in HIV care and management while 90% of them were on ART. Even when majority of them had been encouraged by their peers, spouse or community leader to utilize the HIV services provided by the VHTs, only 59% had sought VHT services for any other reason other than HIV services (Table 2).

Discussion
In this study, the approximately threefold increase observed on willingness by VHT who were HIV positive to utilize HIV services (Table 4) was comparable to related studies done elsewhere in Uganda 16,17 . Community support provided to community health workers through task shifting of specific supervised roles in ART programs revealed an increase in acceptability for HIV services at facility level in rural South Africa 17,18 . This may have been due to the fact that HIV positive people will easily associate with their fellow HIV positive VHTs. However, these studies were conducted among the general population as opposed to this current study where all participants were HIV positive prior to recruitment 16 . The increase in willingness when the VHTs was HIV positive may have been due to the confidence the PLWHAs have amongst their peers of the same HIV status 19 . This kind of confidence perceived may be a result of the PLWHA feeling secure when disclosing to their counterparts 20 . Systematic reviews done about the work of VHTS in improving HV care and management for PLWHA in SSA revealed that VHT clearly enhance uptake of HIV services if appropriate training is provided to them to understand their roles in HIV care and management 21 . Such models may reduce reduced work load among the health workers and also reduced waiting time for the eligible clients for HIV services 22 . This will enable Uganda increase the number of PLWHA receiving ART 23,24 . Policy makers therefore need to consider inclusion of the HIV services in thecommunity health workers program at the district level to increase uptake of HIV services in communities with high HIV prevalence rates 25 . Other studies have also documented the support from various stake holders in the fight against HIV/AIDS for task shifting to community level to reduce the waiting time and work load among health workers attending to these patients 26,27 . However for such task shifting to be effective, community programs need to be driven, owned by and embedded in the communities. Still, an enabling and supportive environment is needed to ensure that task shifting to lay staff and PLWHA is effective and quality services are provided. Finally, a long term vision and commitment from national governments and international donors is required 28 . Findings in this study were comparable to earlier studies done on the role of social and community support and HIV service delivery 27,29 . Peer encouragement, partner support and community leader encouragement were associated with PLWHAs willingness to utilize HIV ser-vices provided by community health workers due to the strong bonds created between the PLWHAs and their relatives. In Uganda still, partner support is crucial and has also been associated with increased use of other maternal and child health services for example of skilled birth delivery 30 and family planning use 31 . In addition, because of stigma PLWHAs tend to disclose their status to their peers in the HIV clinics. VHTs have also been found to offer a conducive environment for disclosure in other parts of Africa 32-34 . Social structures enable PLWHAs to cope and even disclose to other people improving adherence to care and treatment [35][36][37] .
Our study had limitations hence interpretation of findings should be done in light of these. This was a cross-sectional study hence casual temporality could not be ascertained. Recall bias could have arisen since the participants were expected to recollect occurance of past events. We controlled for potential confounders such as socio-demographic characteristics in the multi-variable analysis. Some questionnaires were incomplete and also some particpants opted to withdraw before completion of the interviews.

Conclusion
HIV positive patients are willing to use HIV services provided by Community health volunteers. However, consideration may be given to HIV positive VHTs with whom the HIV positive clients can easily associate with.