Focus group discussion report

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gree you marry ....” (Single female participant, Ahoada). On the whole women made more comments about their fear of the consequences of being positive than men.

Theme 2: Socio-cultural determinants of high risk behaviour In your community is it ok for men/women to have more than one sexual partner?

Both men and women agreed that it was culturally unacceptable for women to keep multiple concurrent sexual partners or have an extramarital relationship but that it was acceptable for men to do so. . Men believed they were created by God to be highly sexually active “but you know say na so God create us” (Married male participant, Ahoada). Women felt society accepts this behaviour from men so there’s nothing they as wives or partners can do about it even if they don’t like it: “na dem style to carry plenty woman, we no get mouth” ( Single female participant, Khana).

What can make a man/woman keep more than one sexual partner?

Women in all groups agreed that women were not likely to engage in risky sexual behaviour if they were married or in a stable relationship. They believed only wayward women who give sex for favours would keep multiple concurrent relationships. They however believed that a woman who was not married could leave a relationship she was not satisfied with for another. “…If the man no dey treat you fine wetin you they find for there?” (Married, female participant, Khana). “... If better person come, e beta make you commot” (Single female participant, Khana). Men felt keeping multiple partners is part of being a man especially if one was not married. “... if you never marry you get to sample!” (Single male participant, Degema). All men accepted that having extramarital affairs or multiple relationships was not the best for them or their families but attribute that behaviour to peer pressure. “To go outside no too good but your guys get to know say you be man”

(Married male participant, Degema).

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What are your views on condom use to prevent HIV infections?

Women in all groups felt condom was a good way to prevent HIV infection but that it was the man’s responsibility to provide the condoms. Most women agreed that they would not procure a condom as it would make them look promiscuous. They also felt that they would feel slighted if their husbands or steady partners used condoms with them. “…e be say im no trust me now or im get another woman” (Single female participant, Degema). Men agreed that those who are unfaithful to their partners should condoms to protect themselves and their families from infection. “Any man wey one do runs, suppose carry raincoat” (Single male participant, Degema). They felt their chances of getting infected were low if they used condoms. Most men however accepted that they found it difficult to use condoms consistently “Condom dey spoil show sometimes, unless you no too trust the girl” (Single male participant, Ahoada).

Theme 3: Factors that influence choice of care provider for STI infections.

In your opinion where do men/women prefer to go to for treatment of an STI?

The discussions indicated that people were not aware that STI services where rendered routinely in the health facilities. Women preferred to seek treatment in the health facility whilst men preferred to go to a chemist shop

What are the possible reasons for these preferred choices?

Women preferred to complain about STI to a health worker for fear that it may compromise their fertility. “If you no treat am well you no go fit born pickin…you get to treat am so e no go worry you wen you won carry belle” (Married female participant, Degema). However, most preferred consulting them at home and not at the health facility. “If we see them for house the ting go dey

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private…” (Married female participant, Khana) . “You fit see the person wey no go carry you talk”..

(Single female participant, Degema) . Men agreed that they preferred to visit Chemist because their services were quick, “…Dey no dey too waste time”…… (Single male participant, Khana) Cheaper,

“...e cost pass to go hospital....(Married male participant, Degema), private and confidential “...dey go sit down listen to you well well” …(Married male participant, Ahoada). Both men and women believed herbal remedies were effective. From the discussions, it appeared that herbal remedies were not sold by traditional medicine practitioners but by chemists and health workers.

What is your opinion on the provision of HIV testing services in places where STIs are treated?

Surprisingly the discussions with men and women in all the groups revealed that integrating STI services with HIV testing services would discourage them from doing a HIV test if they have a choice. “You go to treat infection, dem sey make you do HIV test, chei! Your mind go cut na!”

(Married male participant, Degema) “O boy, fear go catch you!”(Single male participant, Khana)

“if them say make I test, I go go another place go treat myself…” (Single female participant, Ahoada)

Participants suggested health education for the whole community on how to prevent HIV infection will help people adopt safe sexual practices. They also requested for more information on what could be done for persons who are positive. Men wanted more support with disclosure. All parties agreed that improvement in HIV/AIDS service delivery and support for positive persons with improved outcomes for positive people, will greatly improve uptake of HCT.

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CHAPTER 5: DISCUSSION

5.1 OVERVIEW OF RESULTS

Most of the respondents were between the ages of 15-25 years, an economically productive age group yet a large proportion of them were unemployed especially the men (Table 4.2). This is much higher than the National unemployment rate of 19.7%.¹³¹ The fact that 70% of them had at least secondary education (Figure 4.4) but had not gained admission into any tertiary institution and were not gainfully employed creates a pool of vulnerable youth who can easily be recruited into crime and engage in other social vices. Results from the study showed that although most of the respondents were single (Figure 4.3), most of them were sexually active (Table 4.10). Youths in this age group are prone to engaging in risky sexual behaviour. UNAIDS in 2008 estimated that at least 45% of new HIV infections globally occurred between the ages of 15 and 25 years.⁸⁶ They therefore represent a high risk group for HIV transmission underscoring the need to promote HIV testing.

Knowledge of HIV transmission routes was quite high amongst respondents. Over 95% of men and women gave more than five correct answers to the questions on HIV transmission (Figure 4.7). This implies that the level of awareness about HIVAIDS in these communities is quite high which is quite impressive considering the fact that it is a rural community. The fact that most of them were educated could also have influenced their level of knowledge. 46.6% of people got information through the mass media (Figure 4.8) indicating that a good number of persons in these communities have access to the electronic media or newspapers. The next common source of information was from peers (25%). A combination of mass media and Peer-to-peer models may therefore be an effective way to disseminate correct non-stigmatizing messages on all aspects of HIV/AIDS;

transmission, prevention and management in these communities.

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Thirty seven point nine percent (37.9%) of respondents had undergone a HIV test which was greater than the results of the 2007 NARHS where uptake was about 14%. There was no significant difference in the rate of HIV testing amongst women and men (Table 4.3). Most women had their tests done routinely at the health facility (Figure 4.6), an indication that strategies to improve uptake in women such as offering HCT in ante-natal setting, are yielding good results. In men, testing was mostly voluntary (42.8%) and for medical reasons (34.1%). These results were very similar to those in a study by Tchendjou et al in Cameroon.¹³² Because testing in men is largely voluntary, it is also important to ensure that they also have ready access to testing services as disproportionate diagnosis may facilitate gender inequality by promoting gender-based violence and discrimination against positive mothers and their children.

A greater proportion of respondents felt they had low risk for HIV infection (Table 4.5) which was comparable to results from other studies reviewed 12, 56,57,61,62 and goes to show that people generally prefer to assume they have low risk for infection. 24.3% of those who felt they were low risk where classified as high risk after assessment reflecting the fact that people don’t always assess their risk for infection correctly as reported by Moatti et al and Obemeyer.^61,62 This is especially true for men.

Results showed that men’s assessment of their risk was quite poor (kappa <0.148). The fact that high risk behaviours such as keeping of multiple partners and engaging in unprotected sexual intercourse were significantly higher amongst men implies that a good proportion of men may be infected by virtue of their behaviour but may not appreciate the need to test. This is particularly worrisome because testing in men was found to be largely voluntary. They are therefore at risk for late diagnosis of infection with unfavourable outcomes. Focus group discussions revealed that risk behaviours were deeply rooted in socio-cultural norms and it may take a long time to bring about any significant behavioural change. Although all groups recognized condoms as a preventive measure,

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most men and women were not keen on consistent condom use. Discussion revealed differences in the barriers to its use in men and women. Men felt they could not use it consistently because it interfered with sexual satisfaction whilst women viewed it in the context of trust believing that if their partner trusted them, he would not use a condom. Most women also felt that it was a man’s responsibility to ensure condom use when necessary. Obviously, measure to increase the acceptability of condoms as a preventive measure in both gender groups have to be put in place along with other strategies to ensure positive and consistent risk reduction.

Amongst men and women, uptake of testing was similar between those who perceived their risk for infection as high and those who perceived their risk as low indicating that risk perception did not have much influence on HIV testing. This is in contrast to the studies by Lapidus et al and Ndola et al,^56,57 where testing was lower amongst those who felt they had a low risk for infection. Thus, risk perception may not be a barrier to testing in these communities if these services are readily available.

From the focus group discussion, the fear of social stigma if positive was a major concern indicating that stigma does exist within the community. However, few respondents had seen positive persons being stigmatized. This may reflect the fact that most persons would not like to disclose the status of a family member (Table 4.16) and so people cannot readily identify those who are positive. It was surprising that the most common form of observed stigma was discrimination in access to health care. This is a very unacceptable trend that needs to be addressed. Studies have shown that widespread stigma in a community exerts negative effects on individual’s acceptance of HIV testing.¹³³ In this study, observing enacted stigma did not seem to have any influence on uptake of testing (p=0.137).

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Although Fewer people had stigmatizing attitudes towards positive persons (Figure 4.10), uptake of testing was significantly influenced by the tendency to stigmatize (p =0.000). Weiser et al also observed a similar association in a study in Botswana ⁷⁰. The odds of not testing with a high stigmatizing attitude was 2.124 in women (CI =1.322-3.411) whilst in men it was 1.778 (CI=1.042 – 3.032). In the focus group discussion, the most common view about positive persons was that they were promiscuous. These stigmatizing attitudes are the reasons why HIV/AIDS stigma exists because they often lead to negative reactions to positive persons and need to be corrected if HIV interventions are to succeed. Identifying the commonest forms of stigma in community can serve as a guide on how anti-stigma messages should be addressed. The findings of this study gave an insight into the predominant forms of stigma in these communities. The commonly expressed form of stigma in the study population was being ashamed of a family member who is positive and blaming positive persons for their disease (Table 4.16). Anti-stigma messages should therefore address these issues.

Over 50% of respondents had a history of STI in the last one year. This is an indication of the level of sexual networking that exists in these communities. More women had a past history of STI compared to men (Figure 4.12). Considering association between HIV and STI and the fact that women are more vulnerable to HIV infection,¹³⁴ this finding has strong implications for HIV transmission within the community.

Most persons with a history of an STI had sort treatment from the health centre or chemist (Figure 4.13). There were no significant gender differences in choice of care provider. This is unlike the reports from other studies in Africa where most persons (men and women) sort treatment for STI from the informal sector, ^135-137 these responses appeared to be subjective and may not reflect true actions as observed by Onwujekwe et al.⁹⁹ For instance, the results from the focus group discussions

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showed that most men said they would prefer to seek treatment from a chemist because service was quicker cheaper and more confidential. Women preferred to see a health worker but not at the health facility also because of concerns about confidentiality.

From the focus group discussion, there is a probability that quite a number of persons in the community prefer to treat STI in places other than the health facility. If this is true, then it would greatly compromise HIV testing uptake. The results showed that a significant proportion of those who visited chemists and traditional healers had not tested for HIV whilst on those who had who sort treatment in the health centre where likely to have undergone a HIV test (Table 4.27). Where people only seek treatment at the health facility when their symptoms are severe, it reduces the chances that they would have access to early diagnosis if infected. Given the fact that the chemist was the most preferred alternative choice of care, it is possible that a lot of persons who are at risk will not benefit from testing if they are not educated on the importance of seeking care in the health facility where staffs are adequately trained to provide appropriate treatment.

On the whole, there were no significant gender differences in behaviour and attitude to HIV testing in these communities in contrast to similar studies by Stein et al and Gipson et al.^{34, 36} This may be an indication that women are beginning to make decisions for them and that the gender gap is slowly decreasing in these communities.

5.2 CONCLUSION

The results show that stigmatizing attitude and poor utilization of facility based STI services may constitute the major obstacles to utilization of HCT services in the study population. Strategies to address these two issues so as to improve the acceptability of HIV testing may facilitate early diagnosis of HIV infection and reduce AIDS mortality.