Knowledge, attitude, willingness of HIV counseling and testing and factors associated with it, among long distant drivers in Enugu, Nigeria: an opportunity in reduction of HIV prevalence

Background Long distance truck drivers (LDTDs) have been one of the key forces in the spread of HIV/AIDS across the African continent. Objective We set out to assess the knowledge of HIV transmission route, preventive measures, attitude to HIV Counseling and Testing (HCT), willingness and factors associated with willingness to screen for HIV among long distance truck drivers in Enugu, Nigeria. Method This was a cross-sectional study of 500 long distance truck drivers aged 19–65 years. They were interviewed with a semi-structured questionnaire on aspects of HCT. Data was analyzed using cross tabulations to examine associations and chi square test for various variables. Result A good number of the respondents have wrong ideas of transmission route, ranging from 28.4% to 90.4%. Significantly high number of those with tertiary education will engage in incorrect preventive measures like using antibiotics after sex, and seeking protection from a traditional healer compared to those with no formal education ( χ 2 = 3.2, p = 0.02; χ 2 = 2.3, p = 0.01 respectively).. Those with tertiary education and those that were divorced showed a generally good attitude towards HCT and mostly agreed that HCT should be made compulsory compared to others (χ2 = 29.8, p< 0.001; χ2 = 10.1, p < 0.001 respectively). There was a significantly high willingness to screen among 302 (60.4%) of the participants. There was also significant association between marital status, educational level and willingness to screen ( χ2 = 174.4, p < 0.001; χ2 = 10.6, p < 0.001 respectively). Conclusion A high number of LDTD had wrong knowledge of transmission route, better educational level did not affect incorrect knowledge of preventive measures, educational and marital statuses affected attitude to HCT, willingness to screen was high with marital status and educational level significantly associated with it. We recommend routine HCT at the work places of truck drivers to correct the anomalies discovered above.


Introduction
Human Immune Deficiency Virus infection and Acquired Immune Deficiency Syndrome (HIV infection and AIDS) has become pandemic and one of the challenges facing African countries [1][2][3] . It started in Nigeria in the 1980s and is now a generalized epidemic, with prevalence of 3.1% 4 . It showed a prevalence range of 0.9 -15.4% from sen-tinel Antenatal clinic sites, with Zamfara state having the lowest prevalence of 0.9% in Nigeria and Benue state having the highest of 15.4% 5 . Enugu State where this study was carried out has a prevalence of 4.9% 5 . Certain occupations have been associated with an increased risk of acquiring HIV/AIDS. Long distance truck drivers (LDTDs) are one of such 6,7 . Away from the comfort of their wives and homes, families and social environments; for a prolonged period of time that sometimes stretch into months, most truck drivers engage in regular sex with both female and male sex workers, including multiple sex partners 8 . Prevalence of HIV among most at -risk persons and their partners (brothels and non-brothel based female sex workers, men who have sex with men, long distance truck drivers and injection drug users) remains high and accounts for 32.2% of new infections. 9 A study conducted by Federal Ministry of Health (FMOH) 2010 indicated that HIV prevalence stood at 27.4% for brothel based female sex workers (BBFSW), 21.7% of non-brothel based female sex workers (NBBFSW), 17.2% in men that have sex with men (MSM), 4.2% in intravenous drug users (IDU), and 2.4% in transport workers. 10 A behavioral surveillance survey conducted in Nigeria in 2000 reported that only 13% had ever been tested for HIV 8 . Another work conducted among LDTD in South east Nigeria showed that 43.7% were previously screened, 54.8% were willing to undergo HIV screening test if offered freely 11 . In our study, educational status of the drivers was a significant determinant of willingness to screen, with the more educated showing higher frequency of willingness to be screen. In SouthWest Nigeria, 61.3% of LDTDs were willing to uptake HCT services 12 . In this study, perceived possible hindrances to HCT uptake were fear of a positive HCT test (86.2% of respondents), stigmatization in 86.7%, lack of in-depth knowledge about HCT in 86%, confidentiality concerns (89%), and poor access to HIV testing services (50.3%). Also older age, car drivers and higher education were factors favoring willingness to uptake of HCT services. One of the most important tool for prevention is HIV counseling and testing (HCT) [13][14][15] . It is a process by which an individual undergoes counseling to enable him/her make an informed decision or choice about being tested for HIV. It is entirely voluntary or provider-initiated and it is confidential [16][17] . However, in many countries, less than 50% of the vulnerable groups patronize these services, more out of fear of a possible positive result and the related stigma and discrimination that is associated with the infection, than ignorance of the existence of the service 7,18,19 . Therefore this study aimed to evaluate the knowledge, attitude, willingness to HCT and factors associated with willingness to screen among long distance truck drivers, with a view to gain insight into their behavior and lifestyle that may be related to increasing the uptake of HCT among them, thus limiting the spread of the disease.

Methods
This was a descriptive analytical cross-sectional study of long distance truck drivers, conducted from January 2010 -March 2011 at the 9 th Mile Corner motor park, Ogbete main market park and the Holy Ghost Park, Enugu State, South East Nigeria. The 9 th Mile Corner, as the name implies is nine miles to Enugu metropolis. It is well known for transportation business and a link to other neighboring towns in Enugu State and states in the Middle belt regions of Nigeria. The 9 th mile corner has not less than 100 long distance drivers working along that route. The state is bounded by five other states with which it shares common boundaries. Network of roads connect important centers of trade and industry in the state and are the link between the South-East geo-political zone and the middle-belt and have many very busy truck terminals. The 9 th mile corner, where the 9 th mile motor park is located is in Ngwo part of Enugu. Ngwo has been long known for coal mining activities. The Nigeria coal corporation has been based in Enugu since 1950 where it controlled coal mining 20 . Brewing and soft drink bottling are among other industries in Enugu located at the 9 th mile corner 21,22 . Trailer vehicles carrying raw materials and taking the finished products for the Northern part of Nigeria via Makurdi and to the MidWestern part of Nigeria via Onitsha and Asaba, pass through 9 th mile. Health care services can be obtained at several tertiary health institutions including Enugu state university teaching hospital, University of Nigeria teaching hospital, National Orthopaedic hospital, Enugu and Federal Neuropsychiatric hospital Enugu. There are also several government owned health centers and many private hospitals that serve the residents of Enugu, including people living in the 9 th mile area 23,24 . A lot of petty traders hawk their wares at the 9 th mile with night travels to and fro especially to the Northern part of the country very common. As a result there are sleeping inns and hotels around where commercial sex workers prowl.
Consecutive recruitment of LDTDs, who satisfied the inclusion criteria was done. The inclusion criteria were all LDTD and their assistants present in the concerned motor parks at the time of study, they must be aged 18 years and above, and must have been driving or assisting for not less than 1 year. They must give informed consent and understood English, Igbo or Pidgin English ( a local version of English language). Those who did not give their consent and non-drivers found in the motor parks were excluded from the study. Those less than 18 years and those who had not been up to 1 year on the job were excluded. The drivers were identified by their names and identities provided in the records of their respective fleet management offices in the various parks. This helped us eliminate the possibility of duplication. The interview took place at their eating places inside the motor parks. The objectives of the study were explained to them and confidentiality assured by non-inclusion of self-identifying characteristics in the questionnaire. Documentation was made of their socio-demographic characteristics and their Knowledge of HIV/AIDS, attitude to risky sexual behavior and willingness to screen for HCT. Ethical clearance was given by the University of Nigeria Teaching Hospital (UNTH) Ethical Committee and the Bioethical Committee of the Ministry of Health Enugu State. Permission from authorities of the motor park unions and informed consent were obtained.
Four assistants were recruited and trained on the objectives, methods of administration and collection of the questionnaire. The questionnaires were checked and sorted out manually by the author and the data obtained analyzed using SPSS statistical software package Version 19.0. Some open ended questions were used in the questionnaire e.g. where the respondents were require to fill in "others…" options. Correct knowledge of HIV transmission route was defined as transmission through the following routes: sexual intercourse, blood transfusion, mother to unborn child, pregnancy, delivery, breast feeding and sharing sharp objects. Incorrect transmission routes included: sharing eating utensils, mosquito/ bed bug mites, witchcraft, kissing and hugging/handshake. The analysis consisted of tabulations to examine relationships. Stratification in terms of educational level and marital status was done to assess the effect of these on willingness to screen and attitude to HCT. The Chisquare test was used for variables. Statistical significance was considered present when p value was less than 0.05. Confidence Interval was 95%.

Results
Five hundred LDTDs were recruited for the study. Five hundred and fifteen questionnaires were distributed, 10 were incomplete and improperly filled, 5 refused to participate for undisclosed reasons. Respondents were all males and most of them, 443 (88.6%) were within the age groups 20-49 years. The mean age of the respondents was 38.3 ± 8.6 years. Two hundred and fifty eight (51.6%) had secondary or higher level education while (48.4%) had primary or no formal education. Majority of them were married 288 (57.6%), Ibos 417 (83.4%) and of Christian religion 444 (88.8%). Up to 29.4% were single, table 1.  were correct preventive measures that demonstrated significant differences in their response in accordance to their educational level. Majority of those with tertiary education will want to delay their onset of sexual inter- course (63%) and avoid sex with CSWs (27%), compared to 18% and 4.3% of those without formal education (c2=22.2, p < 0.001; c2=12.5, p < 0.001 respectively). 91.4% and 74.2% of the respondents demonstrated an incorrect preventive knowledge of seeking protection from a traditional healer and going for check-ups after sex respectively. It is also pertinent to note that significantly higher number of those with tertiary education will engage in incorrect preventive measures, like using antibiotics after sex and seeking protection from a traditional healer (90% and 100%) respectively compared to those with no education (69% and 86%), χ2 = 3.2, p = 0.02; χ2 = 2.3, p = 0.01 respectively.  Table 3 showed the attitude of Nigerian LDTDs to HCT in terms of educational and marital status. It also divided their attitudes into positive and negative aspects. Those with tertiary education and those that were divorced showed a generally good attitude to HCT than the others. Their response showed a significant difference as to whether HCT should be compulsory for everybody (c2= 29.8, p < 0.001; and c2= 10.1, p < 0.001 respectively). Those with tertiary education and those that were divorced were more likely to agree that HCT should be made compulsory. For negative attitudes to HCT, there were no significant differences in terms of educational and marital status. However, it should be noted that none of the respondents with tertiary education demonstrated a negative response to HCT. Table 4 demonstrated the willingness to screen of LDTD in relation to educational and marital status. There was a significant association between marital status, educational status and willingness to screen, c2= 174.4, p < 0.001; c2=10.6, p < 0.001 respectively. Most of the married were willing to screen (75.8%), while 62.1% of the singles were not. All with tertiary education were willing to screen. As high as 55.1% of those with secondary education were not willing to screen.

Discussion
The main findings of the study were a generally good knowledge of prevention of HIV/AIDS among LDTD, ranging from (69% -100%) across the educational levels. However, it is interesting to note that in spite of this, sex with commercial sex workers and not being faithful to one's partner showed a significantly poor response as a preventive measure; only 3.6% -27% and 2.1% -8% across the various educational levels respectively gave the right responses, table 1. Other unproven methods of prevention were noted to be very common among LDTD's e.g. the use of antibiotics after an act of unprotected sex, going for medical checkups after having sex not necessarily going to check their HIV status, and protection from a traditional healer with wrong responses ranging from 69% -100%. Abstinence, being faithful to one's partner and the use of condom are the basic rudiments of HIV prevention. This observation is similar to other studies in the developing countries 25,26,27 . In one of these studies carried out in 17 countries of Africa, it was shown that more than half of young people did not know how to protect themselves from HIV 27 . There was a generally good attitude to HCT in the range of 54.3% to as high as 90.9% across the various educa- tional groups. Some of the LDTD thought it should be compulsory for everybody. However this does not translate to the practice of HCT. Out of the 500 LDTDs that were studied, only 17.0% had practiced HCT (not reflected in the tables). This did not agree with previous studies which noted negative attitude and practice of HCT 28,29 . These changes may be due to increasing information and awareness as already observed. Again, in developed countries with better health facilities, higher literacy level, awareness and resources, the uptake of HCT is very high 30 .
The married were more likely to practice HCT (24.7%) than the single (4.1%), and practice of HCT was found to be associated with the highest educational level attained by the respondents. The reasons given by Nigerian long distance drivers for this poor practice of HCT were lack of knowledge of where to go for HCT in about half of them (51%). Studies done in some African countries showed that HCT services were not widely available, especially outside the main or urban centers 15,19,31 ,. In most health institutions in Nigeria, HIV testing is limited to diagnostic purposes and is not available to people in the general population interested in knowing their sero-status 15,27 . This has a serious public health implication in the efforts to stem the HIV pandemic. An HIV positive person with unknown sero -status is a great danger to the public. The relationship between marriage and the high uptake of HCT among long distance drivers may be due to the compulsory screening embarked upon by churches in the bid to curb the spread of the disease among intending couples and their unborn children.
Our study further revealed that fear and anxiety accounted for 37% of why long distance drivers did not practice HCT. This is similar to findings from other studies done in developing countries 31,32 . It is a fact that people living with HIV/AIDS are stigmatized and discriminated against. These negative effects of living with HIV/AIDS create an atmosphere that discourages effective prevention by dissuading persons from coming freely for testing and from seeking information on how to protect themselves and others 33,34 . It has also been shown by studies that ignorance, poor perception of individual risk, and the widespread stigmatization and discrimination associated with the disease are other factors limiting the practice of HCT 15,27 . These negative responses and attitudes towards people living with HIV/AIDS (PLWHA) are strongly linked to the general level of knowledge about the disease and in particular, to the causes of HIV and its mode of transmission. In most societies, AIDS is associated with groups whose social and sexual behavior does not meet with public approval 35 . The main factors that have been identified as contributing to HIV/AIDS related stigma are the fact that HIV/AIDS is a life threatening disease which people are afraid to contract.
Although this study noted a higher perception of risk for HIV infection in about 76% of them, it also in about 60.4%, showed a high willingness to screen. This finding is somewhat better in terms of willingness to screen than previous studies by Wilson, et al. In their 1995 and 1997 surveys, they found that 37.9 and 39.1% of the drivers, respectively, considered themselves to be moderately or highly at risk of contracting HIV but only 30% of them were willing to screen for HIV. This poor willingness to screen in their study may due to early period of study, when little was known about the disease and the driver's poor perception of individual risk of contracting the disease. However much has not changed in this regard due to reluctance to reach out to key populations such as sex workers, people who inject drugs, transgender people, prisoners, and gay men and other men who have sex with men 36 . Educational level and marital status were associated with willingness to screen in our study. All LDTDs with tertiary education were willing to be screened for HIV, while most married long distance drivers were willing to be screened. This study has its limitations. Owning to the cross sectional nature, findings should be interpreted as associations rather than implying causality. As the sample was not a perfect random one, some selective bias may exist. Another limitation of the analysis are non-response bias, however the relative high response rate (97%) might minimize this bias. Our questionnaire might not reflect all aspects of knowledge, attitude, willingness to screen and its associated factors. Also population of long distance drivers is highly mobile, so we cannot say that we interviewed a sample is 100% representative of the drivers in the various motor parks. Despite these limitations, our findings provide valuable information for HIV test.

Conclusion
Our study showed that more than half of the long distance drivers have wrong ideas of HIV transmission route. Significant number of better educated respondents had wrong knowledge of preventive measures, although generally there was good knowledge of HIV preventive measures. Educational level and marital status were significantly associated with attitude to HCT. There was high willingness to screen for HIV infection among the respondents. This was also associated with the level of education and marital status.

Recommendations
From the findings of our study, strengthening the existing prevention strategies is the way to go. Emphasis on knowledge of HIV transmission routes and prevention and countering misconception of HIV transmission modes should be stepped up. Provision of free mobile HCT centres within the motor parks to increase accessibility to testing will also be good.
Misconceptions about the unproven and unscientific means of transmission and negative attitudes should be dissuaded through adequate information by means of public awareness campaign. This can be achieved by proper coordination between the individual health care providers, the mass media, the educators, the non-governmental organizations and the government as policy formulators; in conjunction with various truck park representatives who should be given a short term but well packaged training in HCT adapted for use among their colleagues.