Trends in Human Immunodeficiency Virus (HIV) Testing and Counseling, Midlands Province, Zimbabwe, 2010 to 2014   Annamercy Makoni1, Notion Gombe1, More Mungati1, Donewell Bangure1, Mufuta Tshimanga1, Milton Chemhuru2  1. Department of Community Medicine, University of Zimbabwe 2. Ministry of Health and Child Care, Zimbabwe I’m here to present to you results of the HIV Testing and Counseling Trends Analysis for Midlands Province, Zimbambe for the period 2010 to 2014

Introduction HTC, entry point to HIV prevention, behavior change, treatment , care and support Globally, 118 million people received HTC (WHO 2013) In sub Saharan Africa, 10% men and 15% women (15-24 years) knew their HIV status (WHO 2013) In Zimbabwe, 36% men and 57% women received HTC (ZDHS 2010/11) HIV testing and counseling is the critical first step in linking people living with HIV to the treatment cascade, and it also provides an important opportunity to reinforce HIV prevention [2]. The knowledge of one’s HIV status is an important prevention and treatment intervention strategy that influences behaviour change [1]. According to the World Health Organization, 118 million people received HIV testing and counseling worldwide. In sub Saharan Africa, 10% men and 15% women between the age of 15 and 24 years knew their HIV status in 2013 The Zimbabwe Demographic Health Survey of 2010/2011 recorded that 57% of women and 36% of men had been tested for HIV and received their results.

Community/NGO/Workplace Flow of HTC Data . Responsible person Level National M&E and Health Information Team National Feedback Provincial Health Executive/ HIV Focal Person/Health Information Officer Provincial Data District Health Executive/Health Information Officer District Figure 1 shows the flow of HIV Testing and Counseling Data from the community to the national level. The HTC dataset was set up in 2006. HTC indicators are captured for programming , decision making and monitoring and evaluation purposes at all levels. HTC service providers submit monthly data to local health facilities. At the health facility data are consolidated monthly into the HIV monthly return form and send to the district At the district the data will be received and consolidated into a district report. The district health information department enters the data into the electronic District Health Information System 2 software which can be accessed at the provincial and national levels. National annual HTC reports are produced by the Ministry of Health and Child Care and feedback is given to health facilities The Ministry of Health and Child Care ensures that ongoing research is carried out to address specific program gaps. A preliminary review of Midlands province health facility based HTC data showed that a small proportion of men were being tested for HIV as compared to women. We therefore set out broadly to analyzed the secondary HTC data for the period 2010 to 2014 to determine trends. Health Information Officer/Matron/ Nurse Manager/ Data entry Clerk Health Facility Community/NGO/Workplace Source: Zimbabwe National Guidelines on HIV Counseling and Testing, 2nd Edition, 2014

Specific Objectives To assess proportion of clients tested for HIV by age group To compare HTC trends by district To determine HIV positivity rates by age, sex, district To determine HIV positivity rates among individuals who were tested as couples And specifically To assess HIV testing and counseling trends by age group To compare HIV testing and counseling trends by district To determine HIV positivity rates by age, sex and district To determine HIV positivity rates among individuals who were tested as couples by age group

Materials and Methods Design: Descriptive study- secondary HTC data Sampling: All HTC records, 2010-2014 Data Analysis: Graphs showing trends-Microsoft Office Excel 2007 Chi Square for trends and p-values - Epi infoTM Version 7 Permission: PMD Midlands, Heath Studies Office Ethical considerations: No identifiers were used We carried out a descriptive study using secondary HTC data . All HTC records for Midlands Province from 2010 to 2014 were analyzed. Data were analysed using Microsoft Excel to generate graphs. Chi-square for Trends and p-values were generated using Epi Info version 7. Permission to proceed was obtained from the provincial medical director and the health studies office. All ethical considerations were duly observed including the non use of identifiers

RESULTS The next 10 slides will showcase our results….

HIV Testing and Counseling Data Completeness and Timeliness, Midlands Province, 2013 to 2014 This graph shows the quarterly data quality rates for HTC data in Midlands province from 2013 to 2014 in terms of completeness and timeliness. There was a gradual increase in completeness and timeliness from 2013 4th quarter to 2014 4th quarter from 73% to 92% and from 15% to 48% respectively. We managed to assess data quality using the DHIS2 software only, which became operational in 2013 4th quarter. 

Socio-demographic Characteristics of HTC clients, Midlands Province, 2010 to 2014 Variable Frequency N= 623 174 (%) Sex Males 244 726 (39) Females 378 447 (61) Age Group <15yrs 67 988 (12) ≥15yrs 555 185 (88) Individuals tested as couples <19yrs 20-49yrs 50+yrs n= 43 898 (%) 3737 (9) 35 376 (81) 4 786 (10) There was a total of 623 174 clients in the dataset from 2010 to 2014. Of these, 7% were tested as couples. 62% of the individual clients who received HTC services were female and 88% of the clients were 15 years and above

Proportion of Clients Tested for HIV, Midlands Province, 2010 to 2014 This graph shows a significant increase in the proportion of clients receiving HTC from 4% in 2010 to 21% in 2014. A sharp increase was noted from 2013 to 2014 from 6% to 21%.

Clients Tested for HIV by Age group, Midlands Province, 2010 to 2014 This figure shows that a small proportion of children below 15 years were tested for HIV. However, there was a sharp increase in clients who were tested and counseled for HIV in both age groups The increase in clients who received HTC from 2010 to 2014 was statistically significant for both age groups The difference between the two trends was statistically significant X2= 79 851; p<0.01 and X2= 207 138; p<0.01 respectively., with p< 0.01 and chi square value of 19.8;

Clients tested for HIV by District, Midlands Province, 2010 to 2014 The graph shows a significant increase in the proportion of clients tested for HIV across all districts from 2010 to 2014 All the districts recorded the highest proportion of clients tested for HIV in 2014 with Mberengwa having the highest proportion of 22% and Gokwe with the lowest proportion of 14%.

Trends in HIV Positivity, Midlands Province, 2010 to 2014 HIV positivity for the province significantly declined from 29% in 2010 to 7% in 2014

HIV Positivity by Age group, Midlands Province, 2010 to 2014 There was a significant decline in HIV positivity across all age groups. HIV positivity was higher in the 25 to 49 years age group and declined from 36% in 2010 to 13% in 2014

Trends in HIV Positivity by Sex, Midlands Province, 2010 to 2014 The graph shows a significant decline in HIV positivity rates for both males and females. However males had higher positivity rates than females from 2010 to 2014. The difference between the two trends was statistically significant X2= 8 383.6; p<0.01 and X2= 18 811.3; p<0.01 respectively. with a p value< 0.01and chi square 280

HIV Positivity by District, Midlands Province, 2010 to 2014 All districts show a decline in HIV positivity rates from 2010 to 2014, Gweru district with the highest rate of 50% in 2010. Gokwe district had the highest positivity rate of 43% in 2011 and the lowest in 2014.

Positivity Rates among Clients tested as Couples, Midlands Province, 2010 to 2014 Individuals in the 20 to 49 years age group who were tested as couples had the highest positivity rates from 2010 up to mid-2012 From 2013 to 2014, the above 50 years age group showed higher HIV positivity rates. with X2= 68.9; p<0.01, X2= 708.2; p<0.01 and X2= 26.9; p<0.01 respectively.

Discussion Increase in HTC in all age groups, districts Increase in testing centers Integration of HIV and AIDS with other programs Massive HTC campaigns in 2014 Consistent with findings by Appiagyei et al, Lusaka (2012) Low HTC in Gokwe relative to other districts Inadequate HTC sensitizations Hard to reach populations Implies failure to prevent transmission Need to integrate HTC with other outreach programs Our Discussion Few children were tested for HIV in the province throughout the period 2010 to 2014. Children do not know the importance of knowing their HIV status and how HIV is transmitted. They cannot decide on their own to go for HIV testing or seek medical care because they are dependent on their care givers. Only the exposed infants, children with HIV related illnesses and school going children who want to be circumcised are tested for HIV. Failure to catch them young means failure to reduce HIV transmission and delayed treatment. Similar findings were reported by Sanga et al in Tanzania were HTC coverages were lower among children. The significant increase in HIV testing in all age groups and across all districts is attributed to the increase in the number of health facilities offering HIV testing over the years The integration of HIV and AIDS with other programs through the provider initiated testing and counseling at the health facilities The Provincial HIV Focal Person for Midlands province highlighted that the year 2014 recorded the highest HTC coverages due to the massive campaigns which were done that year Appiagyei et al in 2012 in Lusaka, noted high coverages of HTC due to a mass media campaign, however coverages declined as the campaign ended [8]. This implies that HTC campaigns should be done routinely to maintain high coverages in order to achieve the first 90 target in the next 5 years According to the key informants interviewed, the low HIV testing and counseling coverage in Gokwe district was attributed to its inadequate sensitization campaigns due to hard to reach populations. This implies failure to reduce HIV transmission and to provide early treatment in the district Integrating HIV testing and counseling with other outreach programs would increase testing coverages at a low cost

Discussion Higher positivity rates among males Poor health seeking behaviors High proportion of men tested were HIV positive Consistent with findings by Sanga et al, Tanzania Need to reach men where they are found Peer mobilisers and counselors General decline in HIV positivity rates expansion of HTC through PITC Changes in sexual behaviour Condom programming The higher positivity rates among males might be attributed to the poor health seeking behaviors of men. Men present to the health facilities when they are already sick and a significant proportion of them test positive for HIV. This is supported by findings by Suthar et al, who found out that health facility based HTC positivity rates were higher than the community based rates This implies that men need to be sensitized to go for HTC before they become sick so that they get early treatment and prevent HIV transmission The general decline in HIV positivity rates in all age groups, sexes and districts may be attributed to the expansion of the HIV testing and counseling services through the Provider Initiated Testing and Counseling initiative at all entry points, Condom programing and behaviour change among married couples  

Limitation Health facility data were used to determine trends hence can not be generalized As a limitation to our analysis, health facility data were used do determine trends, hence can not be generalized

Conclusion Significant increase in number of clients tested for HIV across all age groups, sexes and districts HIV positivity rates significantly declined across all age groups, sexes and districts Positivity rates were significantly higher among males than females We therefore concluded that: There was a significant increase in the number of clients tested for HIV across all age groups, sexes and districts in Midlands province HIV positivity rates significantly declined across all age groups, sexes and districts And Positivity rates were significantly higher among males than females

Recommendations Routine HTC campaigns in order to reach men (already being done) - Provincial Health Promotion Officer Community based HTC services- Provincial Nursing Officer/ Provincial Health Promotion Officer An analytical study on determinants of HTC uptake among males- Public Health Officer From the dataset analysis we would have recommended routine HTC campaigns in order to reach men but through our consultations, this was already being done Integrating HTC with other outreach programs for cost effectiveness. And an analytical study on determinants of HTC uptake among men,

Public Health Actions Shared results with the Provincial Health Executive team, recommendation to conduct routine HTC campaigns twice a quarter was taken up A study on factors associated with male partner involvement in the prevention of mother to child transmission of HIV (PMTCT) was conducted in the province. Findings of the analysis were shared with the Provincial Health Executive team and as a result the recommendation to conduct routine HTC campaigns twice a quarter instead of once a quarter was taken up Following the recommendations from this analysis, a study on factors associated with male partner involvement in the prevention of mother to child transmission of HIV was conducted in the province.

Acknowledgements Provincial Medical Directorate, Midlands Ministry of Health and Child Care, Zimbabwe Centre for Disease prevention and Control, Zimbabwe MPH-FETP Colleagues, Zimbabwe We would like to thank the following for their input

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