A study presented at the recent Seventeenth Conference on Retroviruses and Opportunistic Infections (CROI) found that Ugandans presenting at a TB clinic grossly overestimated the likelihood that they had HIV.
It also found that those who thought they had HIV were significantly less likely to refer members of their household for HIV testing than those who did not think so.
And it found that if a study member did test HIV-positive, members of their household were much less likely to accept the offer of an HIV test than members of households with no HIV-positive member.
The survey was jointly conducted by researchers from the University of California, San Francisco and Makerere University, Uganda.
The study enrolled 419 patients of unknown HIV status who presented for tuberculosis (TB) evaluation at the Uganda National TB and Leprosy Control Agency in Kampala, Uganda, because their household included someone with active TB. Further details of the study can be viewed on the Makerere University website here.
The patients were part of a study that randomised HIV testing of the patient and members of their household to on-site testing at the TB clinic or to home-based testing by mobile health workers.
Before receiving their test result (in either setting), index patients were asked what they anticipated the result would be and how willing they were to refer other household members for clinic-based or home-based testing.
After they received the result, other household members were asked how willing they were to accept an HIV test (regardless of whether the test result was disclosed).
Most participants were male (62%) and their mean age was 31. Just over 40% of participants were married, just under 40% never had been, and the remaining 20% were separated or widowed.
The first striking finding was that far more participants thought they had HIV than actually did. The actual HIV prevalence in the group was 19% (80 individuals), but fully two-thirds of the group (276 individuals) anticipated a positive result. In fact:
- 18% correctly assumed they were HIV-positive
- 33% correctly assumed they were HIV-negative
- Only 1.4% of the group thought they were HIV-negative when they in fact had HIV
- 48% of the group thought they were HIV-positive when they did not have HIV.
The other striking finding was that people who anticipated having HIV were less likely to discuss HIV within their households, 70% less likely to refer other family members for testing at the TB clinic (p = <0.01) and 53% less likely to refer them for testing at home (p =< 0.05).
Furthermore household members of index patients who tested HIV positive were 54% less likely to accept VCT (voluntary counselling and testing) than household members of patients who tested negative, and 78% less likely if the index patient had been tested at home.
The researchers suggest that this is not because HIV was explicitly discussed in households with an HIV-positive member, and people were afraid to test, but rather the opposite: the stigma of HIV meant that HIV testing was less likely to be discussed and normalised in households both where someone did have HIV, and in households where someone did not have HIV but feared they did.
The researchers conclude that “community-level interventions are needed to mitigate the effects of HIV stigma” in order to improve VCT rates and address a situation where the very people more likely to have HIV are those less likely to take a test.