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AIDS prevention and acceptance of HIV testing among residents in Likoma Island, northern Malawi
Transactions of the Royal Society of Tropical Medicine and Hygiene (2009) 103, 885—891
available at www.sciencedirect.com
journal homepage: http://www.elsevier.com/locate/trstmh
Awareness of HIV/AIDS prevention and acceptance of HIV testing among residents in Likoma Island, northern Malawi Hung Che Chiang a,∗, Kwong Leung Yu b, Shue Fang Yap a, Kah Kheng Goh c, Meng Hsuan Mo c, Ta Wei Yang c, Yeh Giin Ngo c, Shu Jung Hsu c, Yi Ching Wu c, Chung Sheng Lai b, Ying Chin Ko a, Po Ya Chang a a
Department of Public Health, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan b Faculty of Medicine, College of Medicine, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan c Taiwan Students without Borders, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan Received 9 August 2008; received in revised form 15 April 2009; accepted 15 April 2009 Available online 22 July 2009
KEYWORDS HIV; AIDS; Knowledge; Attitudes; Practice; Prevention; Health education; Malawi
∗
Summary To evaluate the awareness of HIV/AIDS prevention education, and the acceptance of HIV testing among residents on Likoma Island, Malawi, a cross-sectional, population-based study of 579 residents aged ≥15 years from seven villages on Likoma Island was conducted during July and August 2007. Most of the subjects studied could correctly answer questions about their awareness of AIDS and knowledge of the ways to reduce HIV transmission. Moreover, the proportion of respondents (65.8%) who possessed complete knowledge of HIV/AIDS prevention was greater than the national average. By contrast, condom utilization was slightly lower. Our results also showed that a high proportion of respondents (70.3%) had been HIV tested at any time, 93.5% of them voluntarily. Among correlated factors, females [adjusted odds ratio (AOR) = 1.7, 95% CI 1.1—1.6] and polygamous individuals (AOR = 3.3, 95% CI 1.5—7.0) were more likely to receive an HIV test. Past experience of being HIV tested was a strong predictor of possessing good knowledge and attitudes towards HIV/AIDS prevention. We conclude that antiretroviral treatment provided by Likoma District Hospital has led to the successful scale-up of HIV testing in Likoma Island and consequently improved the awareness of HIV/AIDS. However, the use of condoms remains largely unsupported, and there is therefore still a need to intensify general HIV/AIDS education on the island. © 2009 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
Corresponding author. Tel.: +886 7 3121101x2772; fax: +886 7 3135701. E-mail address: [email protected] (H.C. Chiang).
0035-9203/$ — see front matter © 2009 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.trstmh.2009.04.008
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1. Introduction AIDS is the most serious public-health and developmental challenge in Malawi, as in many other countries in subSaharan Africa. More than two decades since the first case of AIDS was reported in the country, many efforts have been devoted to controlling the epidemic of HIV infection. Key strategies have been implemented progressively, such as promoting public awareness of HIV/AIDS, providing education in order to reduce high-risk behaviours, scaling up antiretroviral (ARV) treatment, and providing HIV testing and counselling.1 The 2004 report of the Malawi Demographic and Health Survey (MDHS) found considerable variations in the level of HIV awareness, according to level of education and place of residence.2 Knowledge of AIDS is universal, regardless of gender, level of education or place of residence. However, beliefs about AIDS vary by residence; urban women are more knowledgeable about AIDS than rural women. The proportion of people with complete knowledge about AIDS is higher in urban (29.4% and 46.4% for women and men, respectively) than rural areas (20.9% and 36.8% for women and men, respectively). Furthermore, the percentage of those receiving an HIV test result in the 12 months preceding the MDHS was also higher in urban areas (5.8% and 13.6% for women and men, respectively) than rural areas (3.1% and 6.1% for women and men, respectively). Likoma Island is an isolated remote area with a welldefined population and is ideal for the epidemiological study of HIV/AIDS transmission and prevention. Sexual relationships with outsiders are significant events, which may occur when the island regularly hosts a small number of visitors, civil servants and well-paid young soldiers. The island is the larger of two inhabited islands situated in northern Lake Malawi, the smaller being the nearby Chizumulu Island, which together make the Likoma district. Among 28 districts in three regions of Malawi, Likoma usually shows incomplete or substantially deficient data in the National Health Statistics. Little is known about the knowledge, attitudes, and practice (KAP) of HIV/AIDS prevention among residents on the island. The purpose of this study was to evaluate the awareness of HIV prevention measures and the acceptance of HIV testing among adult residents of Likoma Island in order to further develop strategies and interventions for HIV/AIDS prevention on this unique island.
2. Materials and methods 2.1. Study context Most of the villages and households on Likoma Island have no electricity or running water, and food is scarce for about 5 months each year. The residents are mainly elderly people and children (50% <15 years old) and there is an unbalanced gender ratio, with noticeably more women than men between the ages of 20 and 40 years.3 Under the policy of Malawi’s National AIDS Commission (NAC) for scaling up ARV treatment, Likoma District Hospital (the major healthcare facility in Likoma, a 30 bed hospital previously known as St. Peter’s Mission Hospital) began providing voluntary HIV counselling and testing (VCT) services
H.C. Chiang et al. in 2003. Also focusing on HIV/AIDS prevention in the area are two major non-governmental organizations (NGOs), the Lake Malawi Projects (LMP) and the Canadian Physicians for Aid and Relief (CPAR). The LMP, a UK-based NGO, has operated an HIV project, ‘AIDS with Us’, on Likoma Island since December 2004. Although its clinic was not fully constructed at the time of this study, it was operating the communitybased ‘Stepping-Stones’ programme to raise the awareness of HIV prevention and treatment in the district. It was also providing Likoma District Hospital with eight trained counsellors to ensure sufficient staff in the hospital to provide HIV testing, and in the community to implement the Stepping Stones programme by travelling from village to village, frequently visiting schools and communities.1 The CPAR aims to improve the delivery of HIV/AIDS programmes in the four northern rural districts, including Likoma.4 This NGO is trying to increase the capacity of community-based organizations to respond to the challenges of HIV/AIDS in their communities through prevention, care and support to AIDSaffected individuals and households. They also participated in the Stepping Stones programme and the training of community facilitators to promote HIV/AIDS awareness.
2.2. Study population and study design The study participants were residents of Likoma Island aged ≥15 years between July and August 2007. A global positioning system (GPS) device (iPAQh2210 Pocket PC; Hewlett Packard, Palo Alto, CA, USA) was used to identify and map the households in seven villages located in the central and northern parts of the island. According to a local government census, the island had a total of 12 villages made up of 7050 residents living in 1190 households during the study period. The seven villages surveyed in this study had 2227 residents living in 734 households, of whom 1114 were estimated to be aged ≥15 years. Oral informed consent was obtained from each participant. Subjects who agreed to participate in the study had the right to refuse to answer any question they wished. Those not at home during the first visit were revisited during our stay in the village.
2.3. Questionnaire interview A structured questionnaire adapted and modified from the Behavioral Surveillance System was used.5 The questionnaire was first translated into the local language, Chichewa, and then translated back into English to ensure accuracy when used by local counsellors. Study participants could choose whether they answered the local language version or the English version. All researchers and local counsellors were trained to conduct the personal interviews using a standard structured questionnaire. The questionnaire included socio-demographic information, knowledge and attitudes towards HIV/AIDS, and participation in highrisk sexual behaviour. A complete knowledge of HIV/AIDS prevention methods was defined as a person who knew at least two of three prevention measures (condom use, faithful sexual partner and abstaining from sexual intercourse), could reject two common misconceptions (HIV can be transmitted by mosquito bites or touching an infected person) and know that a healthy-looking person can be HIV infected.
Awareness of HIV/AIDS prevention in Likoma Island, Malawi
2.4. Statistical analysis To assess socio-demographic characteristics, knowledge and attitudes towards HIV/AIDS prevention, past HIV testing, and high-risk sexual behaviours, descriptive analysis was used. The binary logistic regression model was used to estimate the univariate and multivariate odds ratios and 95% CI for factors related to HIV testing. Knowledge of, attitudes towards and risk behaviours for HIV/AIDS were also subjected to binary logistic regression analysis to identify related and associated factors. All statistical analyses were performed with SPSS 13.0 (SPSS Inc., Chicago, IL, USA). A two-tailed P-value <0.05 was considered statistically significant.
3. Results
Demographic characteristics of respondents
Variable
Total responders
Age (years; mean ± SD)
579
Age group (years) 15—49 ≥50 Female gender
579
579
n (%) 33.4 ± 16.3 469 (81.0) 110 (19.0) 430 (74.3)
Education Illiterate Primary school Secondary school or above
577
Marriage Never Currently Divorced/Widowed
576
Age at first marriage (years; mean ± SD) ≤14 15—19 ≥20
389
Married and living with a sexual partner >1 married partner at once
302
272 (90.1)
390
58 (14.9)
Occupation None Business Student Fishing Services Nyanja ethnicity
Table 2 Knowledge of and attitude towards HIV/AIDS prevention among 579 respondents Variable
n (%)
No. of correct answers among 12 questions (mean ± SD) Identified three prevention measures Rejected two common misconceptions Had complete knowledge of HIV/AIDS preventiona Willing to care for male relative with AIDS Willing to care for female relative with AIDS Keep a secret from anyone outside the family that a family member had AIDSb
8.55 ± 1.56 444 (76.7) 442 (76.3) 381 (65.8) 568 (98.1) 566 (97.8) 339 (59.3)
a
In the seven villages studied, 417 of 734 households (56.8%) were successfully visited, and 579 of 1114 (52.0%) residents aged ≥15 years were included in the study. Among the 579 participants, the mean age was 33.4 ± 16.3 years with 469 participants (81.0%) aged 15—49 years. The sociodemographic characteristics of the participants in the study are shown in Table 1. The major ethnic group in the island Table 1
887
31 (5.4) 360 (62.4) 186 (32.2) 187 (32.5) 303 (52.6) 86 (14.9) 20.9 ± 5.2 11 (2.8) 147 (37.8) 231 (59.4)
579
579
264 (45.6) 113 (19.5) 85 (14.7) 38 (6.6) 33 (5.7) 476 (82.2)
Subjects who knew at least two of three prevention measures (condom use, faithful sexual partner and abstaining from sexual intercourse), rejected two common misconceptions about transmission (mosquito bite and touching infected person) and knew that a healthy-looking person can be HIV infected. b n = 572.
is Nyanja (82.2%). Knowledge of and attitudes towards HIV/AIDS prevention among the respondents are shown in Table 2. Participants’ experiences of being tested for HIV are detailed in Table 3. A high proportion of respondents (70.3%) had been HIV tested at any time, 93.5% of them voluntarily. The KAP of condom use are shown in Table 4. Higher-risk sexual behaviour reported by respondents is detailed in Table 5 and showed that more people used a condom when they had sex with a commercial sexual partner (64.7%) than with their regular partner (24.5%) or a non-regular and non-commercial (53.1%) partner at their last sexual intercourse. Factors that were related to having been tested for HIV are shown in Table 6. In the univariate analysis, being aged 15—49 years (P = 0.002), having never married (P = 0.027), being currently married (P = 0.036) or having a polygamous marriage (P = 0.006) were significantly associated with having been tested for HIV. Women (P = 0.024) and those in polygamous marriages (P = 0.002) were significantly more likely to have been tested for HIV in the multivariate analysis. Predictors for the KAP of HIV/AIDS prevention are shown in Table 7. Statistically significant predictors for possessing complete knowledge were ever having received VCT
Table 3 tested
Respondents’ experience of having been HIV
Variable
Total responders
n (%)
Ever been HIV tested Underwent voluntary testing Knew the result of the test Accepted VCT HIV tested on the island
573 403 403 573 574
403 (70.3) 377 (93.5) 386 (95.8) 386 (67.4) 315 (54.9)
VCT: voluntary HIV counselling and testing.
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H.C. Chiang et al.
Table 4 Knowledge, attitudes and practice of condom utilization among respondents
Table 5 High-risk respondents
Variable
Total responders
n (%)
Variable
Total responders
n (%)
Ever used a male condom Know how to use it correctly Condom can be reused after sexual intercourse (No) Know where to obtain a male condom Know where can male condom be obtained Clinic/hospital Shop/market Family planning centre Can obtain condom close to house or workplace Used condom with regular partner in the past 12 months Never Sometimes Every time
471 565 526
230 (48.8) 328 (58.1) 498 (94.7)
Ever had sexual intercourse
579
456 (78.8)
456
575
485 (84.3)
Age of first sexual intercourse (years) ≤14 15—19 ≥1 non-regular and non-commercial partner in the last 12 months ≥1 casual sexual partner (commercial partner included) in the last 12 months Used a condom with regular partner at last intercourse Used a condom with non-regular and non-commercial partner at last intercourse Used a condom with commercial sexual partner at last intercourse
Reasons for using a condom with regular partner Prevent pregnancy Prevent HIV/AIDS Prevent STIs Partner insisted Reasons for not using a condom with regular partner Didn’t think necessary Used other contraceptives Don’t like to use it Not available Partner objected
515
531
487 (94.6) 341 (66.2) 111 (21.6) 248 (46.7)
230 134 (58.3) 65 (28.3) 31 (13.5) 91 62 (68.1) 53 (58.2) 47 (51.6) 3 (3.3) 190 66 (34.7) 59 (31.1) 48 (25.3) 16 (8.4) 14 (7.4)
services (P = 0.032), being educated to secondary school level or above (P = 0.012) and being currently married (P = 0.021). Factors predicting a greater likelihood of knowing how to use a condom correctly were ever having received VCT services (P = 0.007), female gender (P < 0.001), age 15—49 years (P < 0.001), education to secondary school or above (P < 0.001), being currently married (P = 0.045) and polygamy (P = 0.002). Knowing where to obtain a condom was more likely for those who had ever received VCT services (P = 0.001), those aged 15—49 years (P < 0.001) and those currently married (P = 0.004). On the other hand, those in polygamous marriages (P = 0.007) appeared to be less likely to know how to use a condom correctly. With respect to attitudes towards HIV/AIDS prevention, those aged 15—49 years were 5.8 times more likely to have ever used a male condom (P < 0.001). Females (P = 0.033) and those in polygamous marriages (P < 0.001) were more likely to keep secret from anyone outside the family that one of their family members had AIDS. However, people currently married (P = 0.012) were less likely to have used a condom with their
sexual
behaviour
reported
by
247
26 (5.7) 272 (59.6) 34 (13.8)
247
40 (16.2)
233
57 (24.5)
32
17 (53.1)
17
11 (64.7)
regular sexual partner at the last intercourse. Significant factors predicting extramarital sex included female gender (P = 0.025), age 15—49 years (P = 0.033), being currently married (P = 0.012) and polygamy (P = 0.023).
4. Discussion We did not collect the HIV serostatus of the participants in our study. However, based on over 4000 tests conducted by LMP, their HIV seropositivity rate was 15%.4 This is slightly higher than the average prevalence (12.1%) in the northern region reported by the Malawian DHS survey.6 In the current study, we found that a surprisingly high percentage of respondents had ever been HIV tested (70.3%) when compared with the Malawian national averages for rural areas (27.4% and 23.7% for men and women, respectively).6 Similarly, in a study of UN uniformed peacekeepers in Haiti, 94.7% of respondents reported having had an HIV test at some point in their life with, on average, 69.4% reporting that it had been voluntary.7 The uptake of HIV testing in our study, three-fold higher than the national average, is similar to results from Botswana (78%).8 The high uptake of HIV testing may be due to the aid provided by NGOs and the availability of ARV treatment at Likoma District Hospital since 2005, which may have increased the motivation of residents to be tested. In addition, with the district hospital successfully providing free HIV testing on the island, our findings agree with others that uptake of HIV testing can be expanded by removing structural barriers such as lack of access to free testing,9 inconvenient time,10 inconvenient location and distance,10,11 and shortage of counsellors.8
Awareness of HIV/AIDS prevention in Likoma Island, Malawi Table 6
889
Crude and adjusted odds ratios for having been tested for HIV (n = 579)
Variable
% tested
Univariate analysis
Multivariate analysis
OR (95% CI)
AOR (95% CI)
Gender Male Female
65.5 72.0
1.0 1.4 (1.0—2.1)
1.0 1.7(1.1—2.6)a
Age group (years) 15—49 ≥50
73.4 56.5
2.0 (1.3—3.0)a 1.0
1.5 (0.9—2.5) 1.0
Education Below secondary school Secondary school or higher
67.9 75.7
1.0 1.4 (0.9—2.0)
1.0 1.4 (0.9—2.1)
Income-generating work Yes No
73.1 68.6
1.1 (0.8—1.6) 1.0
1.2 (0.8—1.8) 1.0
Marriage Never Currently Divorced/widowed
71.1 72.2 61.0
1.8 (1.1—3.1)a 1.7 (1.0—2.8)a 1.0
1.3 (0.7—2.2) 1.7 (0.9—3.2) 1.0
Polygamous marriage Yes No
89.5 66.4
2.8 (1.3—5.9)a 1.0
3.3 (1.5—7.0)a 1.0
OR: odds ratio; AOR: adjusted odds ratio. a P < 0.05.
As noted by the preliminary report of the 2004 MDHS,2 huge differences were observed between urban and rural areas in the proportion of young people (15—24 years) with complete knowledge of HIV/AIDS prevention methods, with more rural dwellers lacking such knowledge. The report speculated that the poorer knowledge of HIV prevention in females and rural inhabitants could be due to poor literacy among these groups and reduced access to HIV/AIDS education messages. In addition, the influence of strong cultural beliefs in rural areas may be a major barrier to people absorbing new information on HIV prevention. In the current study, the high education level of the respondents, the penetration of the Stepping Stones programme, free HIV testing services at Likoma District Hospital and the provision of community-based HIV testing counsellors were all positive factors that could have contributed to the residents’ greater knowledge of HIV/AIDS prevention than the national average. Nevertheless, the fact that Likoma Island is a small, isolated area with a discrete population could be another factor making information much easier to disseminate. By contrast, condom use and high-risk sexual activity in our study were at levels similar to national average data reported by the preliminary MDHS 2004.2 The influence of deeply rooted cultural factors could be a reason for the poorer result when compared with knowledge of HIV prevention. However, there are two other possible reasons. Firstly, HIV testing and ARV treatment were only introduced to the island 3 years and 2 years ago, respectively. Thus, observation of behaviour changes needs to be continued for a longer
period. Secondly, participants in our study were allowed to refuse to answer any questions they wished to. Therefore, there may be some bias in reporting of sexual behaviours in our study. Furthermore, regarding the distribution of condoms, Likoma District Hospital provided free condoms to people in post-VCT counselling, and 94.6% of people were aware of the availability of free condoms at the hospital (data not shown). Thus, the poorer utilization of condoms found in our study is not due to insufficient condom availability or accessibility. Some limitations in our study should be mentioned. Not all residents were available for interview when we visited their households and, although we attempted a second visit to those households, there may still be some self-selection involved. In requiring self-reporting of sexual partnerships and condom use there may be some reluctance to discuss private sexual behaviours, resulting in possible underreporting or misreporting. Participants in our study were allowed to refuse to answer questions if they wished. Therefore, there may have been some bias in reporting sexual behaviours in our study. The calculation of an appropriate sample size could avoid this in the future.7 In conclusion, with the aid of NGOs and ARV treatment provided by Likoma District Hospital since 2005, Malawi has successfully scaled up HIV testing in this remote island, and by doing so improved awareness of HIV/AIDS among the residents who accepted the test. The accessibility of condom use needs to be reinforced and enhanced, especially among those who have a regular sexual partner or practice polygamy.
890
Table 7
Multivariate logistic regression models for knowledge, attitudes and high-risk behaviour towards HIV/AIDS prevention
Variable
Ever received VCT services Female gender Age 15—49 years Secondary school or higher Currently married Income-generating employment Polygamyf
Complete knowledgea
Knew how to use correctly
Obtain a male condomb
Ever used male condom
Remain secretc
Used condom with regular partnerd
Extramarital sexe
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95%CI)
OR (95% CI)
2.4 (1.4—4.2)h 0.8 (0.4—1.6) 6.4 (3.4—12.1)h 1.8 (0.9—3.4) 2.7 (1.4—5.3)h 0.9 (0.5—1.7) 0.3 (0.2—0.7)h
0.9 (0.5—1.3) 0.6 (0.4—1.0)g 5.8 (3.1—11.0)h 1.3 (0.9—2.0) 0.9 (0.5—1.8) 1.4 (0.9—2.1) 1.0 (0.5—2.0)
1.0 (0.7—1.4) 1.6 (1.0—2.5)g 1.2 (0.7—2.1) 1.2 (0.8—1.7) 1.3 (0.7—2.2) 1.2 (0.8—1.7) 8.0 (3.3—19.5)h
1.7 (0.8—3.7) 0.9 (0.4—2.1) — 1.5 (0.7—3.0) 0.2 (0.0—0.7)g 2.3 (1.0—5.5) 2.1 (0.6—7.1)
0.7 (0.3—1.6) 0.3 (0.1—0.9)g 10.8 (1.2—96.3)g 1.3 (0.5—3.2) 0.2 (0.1—0.7)g 0.8 (0.3—2.1) 4.3 (1.2—14.9)g
1.5 1.0 1.5 1.7 1.9 0.9 0.7
(1.0—2.2)g (0.6—1.5) (0.9—2.5) (1.1—2.5)g (1.1—3.3)g (0.6—1.4) (0.4—1.2)
1.7 0.4 3.7 2.1 1.9 1.2 0.4
(1.2—2.6)h (0.2—0.6)h (2.1—6.5)h (1.4—3.2)h (1.0—3.4)g (0.8—1.9) (0.2—0.7)h
OR: odds ratio; VCT: voluntary HIV counselling and testing. Reference groups for variables in the table are never had VCT service; male; age ≥50 years; divorced/widowed; non-income generating work; non-polygamous marriage. a Subjects who knew at least two of three HIV prevention measures (condom use, faithful sexual partner and abstaining from sexual intercourse), rejected two common misconceptions about transmission (mosquito bite and touching infected person), and knew that a healthy-looking person can be HIV infected. b Subjects who knew of a place or person to obtain a male condom from. c Subjects who would want to keep a secret from anyone outside the family that one of their family members had AIDS. d Subjects who used a condom with regular sexual partner at last intercourse. e Subjects who had sex with non-marital, non-cohabiting partner in the last month. f Subjects reporting that they were married to more than one partner at once. g P < 0.05. h P < 0.01.
H.C. Chiang et al.
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Authors’ contributions: HCC, KLY, CSL, YCK and PYC designed the study; KKG, MHM, TWY, YGN, SJH and YCW participated in the household interviews and data collection; CSL, YCK and PYC participated in the data interpretation; HCC, SFY and KLY performed the statistical analysis; HCC interpreted the statistical analysis; HCC and SFY drafted the manuscript. All authors read and commented on the manuscript and approved the final version. HCC is guarantor of the paper.
3. Helleringer S, Kohler HP. Sexual network structure and the spread of HIV in Africa: evidence from Likoma Island, Malawi. AIDS 2007;21:2323—32. 4. Canadian Physicians for Aid and Relief. Reducing the burden of HIV/AIDS in rural Malawi. Brief overview of the project. Toronto: CPAR; ©2002. http://www.cpar.ca/ countries.asp?page=malawiredaids [assessed 9 December, 2008]. 5. Amon J, Brown T, Hogle J, MacNeil J, Magnani R, Mills S, et al. Behavioral surveillance surveys: guidelines for repeated behavioral surveys in population at risk of HIV. Arlington: Family Health International; 2000. 6. Malawi HIV and AIDS monitoring and evaluation report, 2007: follow-up to the United Nations Declaration of Commitment on HIV and AIDS (UNGASS). Lilongwe, Malawi: Office of the President and Cabinet, Department of Nutrition, HIV and AIDS; 2007. 7. Elisabeth L, Megh G. HIV/AIDS knowledge, attitude and practice survey: UN uniformed peacekeepers in Haiti. New York, NY: United Nations, Peacekeeping Best Practices Section; 2007. http://www.peacekeepingbestpractices.unlb.org/PBPS/ [accessed 9 Library/KAP survey peacekeepers Haiti.pdf December 2008]. 8. Creek TL, Ntumy R, Seipone K, Smith M, Mogodi M, Smit M, et al. Successful introduction of routine opt-out HIV testing in antenatal care in Botswana. J Acquir Immune Defic Syndr 2007;45:102—7. 9. Nakanjako D, Kamya M, Daniel K, Mayanja-Kizza H, Freers J, Whalen C, et al. Acceptance of routine testing for HIV among adult patients at the medical emergency unit at a national referral hospital in Kampala, Uganda. AIDS Behav 2007;11:753—8. 10. Morin SF, Khumalo-Sakutukwa G, Charlebois ED, Routh J, Fritz K, Lane T. Removing barriers to knowing HIV status: same-day mobile HIV testing in Zimbabwe. J Acquir Immune Defic Syndr 2006;41:218—24. 11. Corbett EL, Dauya E, Matambo R, Cheung YB, Makamure B, Bassett MT, et al. Uptake of workplace HIV counselling and testing: a cluster-randomised trial in Zimbabwe. PLoS Med 2006;3:e238.
Acknowledgements: The authors wish to thank the local team members who helped us to coordinate all matters that made the study work smoothly. The Taiwan Medical Mission in Malawi commissioned the research and provided critical support throughout the study. Funding: The Ministry of Health, Taiwan, sponsored the travel and living expenses for members of Taiwan Students Without Borders during their stay on Likoma Island for 6 weeks. Conflicts of interest: None declared. Ethical approval: The research work was approved by the Taiwan Medical Mission in Malawi and the ethical committee of Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
References 1. Lake Malawi Projects. HIV/AIDS Programme: Aids With Us. Malawi Projects; ©2005. http://www.lakemalawiprojects.org/ projects.html [accessed 25 April 2008]. 2. Malawi Demographic and Health Survey 2004. Preliminary Report. Zomba, Malawi: National Statistical Office; 2005.
available at www.sciencedirect.com
journal homepage: http://www.elsevier.com/locate/trstmh
Awareness of HIV/AIDS prevention and acceptance of HIV testing among residents in Likoma Island, northern Malawi Hung Che Chiang a,∗, Kwong Leung Yu b, Shue Fang Yap a, Kah Kheng Goh c, Meng Hsuan Mo c, Ta Wei Yang c, Yeh Giin Ngo c, Shu Jung Hsu c, Yi Ching Wu c, Chung Sheng Lai b, Ying Chin Ko a, Po Ya Chang a a
Department of Public Health, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan b Faculty of Medicine, College of Medicine, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan c Taiwan Students without Borders, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan Received 9 August 2008; received in revised form 15 April 2009; accepted 15 April 2009 Available online 22 July 2009
KEYWORDS HIV; AIDS; Knowledge; Attitudes; Practice; Prevention; Health education; Malawi
∗
Summary To evaluate the awareness of HIV/AIDS prevention education, and the acceptance of HIV testing among residents on Likoma Island, Malawi, a cross-sectional, population-based study of 579 residents aged ≥15 years from seven villages on Likoma Island was conducted during July and August 2007. Most of the subjects studied could correctly answer questions about their awareness of AIDS and knowledge of the ways to reduce HIV transmission. Moreover, the proportion of respondents (65.8%) who possessed complete knowledge of HIV/AIDS prevention was greater than the national average. By contrast, condom utilization was slightly lower. Our results also showed that a high proportion of respondents (70.3%) had been HIV tested at any time, 93.5% of them voluntarily. Among correlated factors, females [adjusted odds ratio (AOR) = 1.7, 95% CI 1.1—1.6] and polygamous individuals (AOR = 3.3, 95% CI 1.5—7.0) were more likely to receive an HIV test. Past experience of being HIV tested was a strong predictor of possessing good knowledge and attitudes towards HIV/AIDS prevention. We conclude that antiretroviral treatment provided by Likoma District Hospital has led to the successful scale-up of HIV testing in Likoma Island and consequently improved the awareness of HIV/AIDS. However, the use of condoms remains largely unsupported, and there is therefore still a need to intensify general HIV/AIDS education on the island. © 2009 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
Corresponding author. Tel.: +886 7 3121101x2772; fax: +886 7 3135701. E-mail address: [email protected] (H.C. Chiang).
0035-9203/$ — see front matter © 2009 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.trstmh.2009.04.008
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1. Introduction AIDS is the most serious public-health and developmental challenge in Malawi, as in many other countries in subSaharan Africa. More than two decades since the first case of AIDS was reported in the country, many efforts have been devoted to controlling the epidemic of HIV infection. Key strategies have been implemented progressively, such as promoting public awareness of HIV/AIDS, providing education in order to reduce high-risk behaviours, scaling up antiretroviral (ARV) treatment, and providing HIV testing and counselling.1 The 2004 report of the Malawi Demographic and Health Survey (MDHS) found considerable variations in the level of HIV awareness, according to level of education and place of residence.2 Knowledge of AIDS is universal, regardless of gender, level of education or place of residence. However, beliefs about AIDS vary by residence; urban women are more knowledgeable about AIDS than rural women. The proportion of people with complete knowledge about AIDS is higher in urban (29.4% and 46.4% for women and men, respectively) than rural areas (20.9% and 36.8% for women and men, respectively). Furthermore, the percentage of those receiving an HIV test result in the 12 months preceding the MDHS was also higher in urban areas (5.8% and 13.6% for women and men, respectively) than rural areas (3.1% and 6.1% for women and men, respectively). Likoma Island is an isolated remote area with a welldefined population and is ideal for the epidemiological study of HIV/AIDS transmission and prevention. Sexual relationships with outsiders are significant events, which may occur when the island regularly hosts a small number of visitors, civil servants and well-paid young soldiers. The island is the larger of two inhabited islands situated in northern Lake Malawi, the smaller being the nearby Chizumulu Island, which together make the Likoma district. Among 28 districts in three regions of Malawi, Likoma usually shows incomplete or substantially deficient data in the National Health Statistics. Little is known about the knowledge, attitudes, and practice (KAP) of HIV/AIDS prevention among residents on the island. The purpose of this study was to evaluate the awareness of HIV prevention measures and the acceptance of HIV testing among adult residents of Likoma Island in order to further develop strategies and interventions for HIV/AIDS prevention on this unique island.
2. Materials and methods 2.1. Study context Most of the villages and households on Likoma Island have no electricity or running water, and food is scarce for about 5 months each year. The residents are mainly elderly people and children (50% <15 years old) and there is an unbalanced gender ratio, with noticeably more women than men between the ages of 20 and 40 years.3 Under the policy of Malawi’s National AIDS Commission (NAC) for scaling up ARV treatment, Likoma District Hospital (the major healthcare facility in Likoma, a 30 bed hospital previously known as St. Peter’s Mission Hospital) began providing voluntary HIV counselling and testing (VCT) services
H.C. Chiang et al. in 2003. Also focusing on HIV/AIDS prevention in the area are two major non-governmental organizations (NGOs), the Lake Malawi Projects (LMP) and the Canadian Physicians for Aid and Relief (CPAR). The LMP, a UK-based NGO, has operated an HIV project, ‘AIDS with Us’, on Likoma Island since December 2004. Although its clinic was not fully constructed at the time of this study, it was operating the communitybased ‘Stepping-Stones’ programme to raise the awareness of HIV prevention and treatment in the district. It was also providing Likoma District Hospital with eight trained counsellors to ensure sufficient staff in the hospital to provide HIV testing, and in the community to implement the Stepping Stones programme by travelling from village to village, frequently visiting schools and communities.1 The CPAR aims to improve the delivery of HIV/AIDS programmes in the four northern rural districts, including Likoma.4 This NGO is trying to increase the capacity of community-based organizations to respond to the challenges of HIV/AIDS in their communities through prevention, care and support to AIDSaffected individuals and households. They also participated in the Stepping Stones programme and the training of community facilitators to promote HIV/AIDS awareness.
2.2. Study population and study design The study participants were residents of Likoma Island aged ≥15 years between July and August 2007. A global positioning system (GPS) device (iPAQh2210 Pocket PC; Hewlett Packard, Palo Alto, CA, USA) was used to identify and map the households in seven villages located in the central and northern parts of the island. According to a local government census, the island had a total of 12 villages made up of 7050 residents living in 1190 households during the study period. The seven villages surveyed in this study had 2227 residents living in 734 households, of whom 1114 were estimated to be aged ≥15 years. Oral informed consent was obtained from each participant. Subjects who agreed to participate in the study had the right to refuse to answer any question they wished. Those not at home during the first visit were revisited during our stay in the village.
2.3. Questionnaire interview A structured questionnaire adapted and modified from the Behavioral Surveillance System was used.5 The questionnaire was first translated into the local language, Chichewa, and then translated back into English to ensure accuracy when used by local counsellors. Study participants could choose whether they answered the local language version or the English version. All researchers and local counsellors were trained to conduct the personal interviews using a standard structured questionnaire. The questionnaire included socio-demographic information, knowledge and attitudes towards HIV/AIDS, and participation in highrisk sexual behaviour. A complete knowledge of HIV/AIDS prevention methods was defined as a person who knew at least two of three prevention measures (condom use, faithful sexual partner and abstaining from sexual intercourse), could reject two common misconceptions (HIV can be transmitted by mosquito bites or touching an infected person) and know that a healthy-looking person can be HIV infected.
Awareness of HIV/AIDS prevention in Likoma Island, Malawi
2.4. Statistical analysis To assess socio-demographic characteristics, knowledge and attitudes towards HIV/AIDS prevention, past HIV testing, and high-risk sexual behaviours, descriptive analysis was used. The binary logistic regression model was used to estimate the univariate and multivariate odds ratios and 95% CI for factors related to HIV testing. Knowledge of, attitudes towards and risk behaviours for HIV/AIDS were also subjected to binary logistic regression analysis to identify related and associated factors. All statistical analyses were performed with SPSS 13.0 (SPSS Inc., Chicago, IL, USA). A two-tailed P-value <0.05 was considered statistically significant.
3. Results
Demographic characteristics of respondents
Variable
Total responders
Age (years; mean ± SD)
579
Age group (years) 15—49 ≥50 Female gender
579
579
n (%) 33.4 ± 16.3 469 (81.0) 110 (19.0) 430 (74.3)
Education Illiterate Primary school Secondary school or above
577
Marriage Never Currently Divorced/Widowed
576
Age at first marriage (years; mean ± SD) ≤14 15—19 ≥20
389
Married and living with a sexual partner >1 married partner at once
302
272 (90.1)
390
58 (14.9)
Occupation None Business Student Fishing Services Nyanja ethnicity
Table 2 Knowledge of and attitude towards HIV/AIDS prevention among 579 respondents Variable
n (%)
No. of correct answers among 12 questions (mean ± SD) Identified three prevention measures Rejected two common misconceptions Had complete knowledge of HIV/AIDS preventiona Willing to care for male relative with AIDS Willing to care for female relative with AIDS Keep a secret from anyone outside the family that a family member had AIDSb
8.55 ± 1.56 444 (76.7) 442 (76.3) 381 (65.8) 568 (98.1) 566 (97.8) 339 (59.3)
a
In the seven villages studied, 417 of 734 households (56.8%) were successfully visited, and 579 of 1114 (52.0%) residents aged ≥15 years were included in the study. Among the 579 participants, the mean age was 33.4 ± 16.3 years with 469 participants (81.0%) aged 15—49 years. The sociodemographic characteristics of the participants in the study are shown in Table 1. The major ethnic group in the island Table 1
887
31 (5.4) 360 (62.4) 186 (32.2) 187 (32.5) 303 (52.6) 86 (14.9) 20.9 ± 5.2 11 (2.8) 147 (37.8) 231 (59.4)
579
579
264 (45.6) 113 (19.5) 85 (14.7) 38 (6.6) 33 (5.7) 476 (82.2)
Subjects who knew at least two of three prevention measures (condom use, faithful sexual partner and abstaining from sexual intercourse), rejected two common misconceptions about transmission (mosquito bite and touching infected person) and knew that a healthy-looking person can be HIV infected. b n = 572.
is Nyanja (82.2%). Knowledge of and attitudes towards HIV/AIDS prevention among the respondents are shown in Table 2. Participants’ experiences of being tested for HIV are detailed in Table 3. A high proportion of respondents (70.3%) had been HIV tested at any time, 93.5% of them voluntarily. The KAP of condom use are shown in Table 4. Higher-risk sexual behaviour reported by respondents is detailed in Table 5 and showed that more people used a condom when they had sex with a commercial sexual partner (64.7%) than with their regular partner (24.5%) or a non-regular and non-commercial (53.1%) partner at their last sexual intercourse. Factors that were related to having been tested for HIV are shown in Table 6. In the univariate analysis, being aged 15—49 years (P = 0.002), having never married (P = 0.027), being currently married (P = 0.036) or having a polygamous marriage (P = 0.006) were significantly associated with having been tested for HIV. Women (P = 0.024) and those in polygamous marriages (P = 0.002) were significantly more likely to have been tested for HIV in the multivariate analysis. Predictors for the KAP of HIV/AIDS prevention are shown in Table 7. Statistically significant predictors for possessing complete knowledge were ever having received VCT
Table 3 tested
Respondents’ experience of having been HIV
Variable
Total responders
n (%)
Ever been HIV tested Underwent voluntary testing Knew the result of the test Accepted VCT HIV tested on the island
573 403 403 573 574
403 (70.3) 377 (93.5) 386 (95.8) 386 (67.4) 315 (54.9)
VCT: voluntary HIV counselling and testing.
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H.C. Chiang et al.
Table 4 Knowledge, attitudes and practice of condom utilization among respondents
Table 5 High-risk respondents
Variable
Total responders
n (%)
Variable
Total responders
n (%)
Ever used a male condom Know how to use it correctly Condom can be reused after sexual intercourse (No) Know where to obtain a male condom Know where can male condom be obtained Clinic/hospital Shop/market Family planning centre Can obtain condom close to house or workplace Used condom with regular partner in the past 12 months Never Sometimes Every time
471 565 526
230 (48.8) 328 (58.1) 498 (94.7)
Ever had sexual intercourse
579
456 (78.8)
456
575
485 (84.3)
Age of first sexual intercourse (years) ≤14 15—19 ≥1 non-regular and non-commercial partner in the last 12 months ≥1 casual sexual partner (commercial partner included) in the last 12 months Used a condom with regular partner at last intercourse Used a condom with non-regular and non-commercial partner at last intercourse Used a condom with commercial sexual partner at last intercourse
Reasons for using a condom with regular partner Prevent pregnancy Prevent HIV/AIDS Prevent STIs Partner insisted Reasons for not using a condom with regular partner Didn’t think necessary Used other contraceptives Don’t like to use it Not available Partner objected
515
531
487 (94.6) 341 (66.2) 111 (21.6) 248 (46.7)
230 134 (58.3) 65 (28.3) 31 (13.5) 91 62 (68.1) 53 (58.2) 47 (51.6) 3 (3.3) 190 66 (34.7) 59 (31.1) 48 (25.3) 16 (8.4) 14 (7.4)
services (P = 0.032), being educated to secondary school level or above (P = 0.012) and being currently married (P = 0.021). Factors predicting a greater likelihood of knowing how to use a condom correctly were ever having received VCT services (P = 0.007), female gender (P < 0.001), age 15—49 years (P < 0.001), education to secondary school or above (P < 0.001), being currently married (P = 0.045) and polygamy (P = 0.002). Knowing where to obtain a condom was more likely for those who had ever received VCT services (P = 0.001), those aged 15—49 years (P < 0.001) and those currently married (P = 0.004). On the other hand, those in polygamous marriages (P = 0.007) appeared to be less likely to know how to use a condom correctly. With respect to attitudes towards HIV/AIDS prevention, those aged 15—49 years were 5.8 times more likely to have ever used a male condom (P < 0.001). Females (P = 0.033) and those in polygamous marriages (P < 0.001) were more likely to keep secret from anyone outside the family that one of their family members had AIDS. However, people currently married (P = 0.012) were less likely to have used a condom with their
sexual
behaviour
reported
by
247
26 (5.7) 272 (59.6) 34 (13.8)
247
40 (16.2)
233
57 (24.5)
32
17 (53.1)
17
11 (64.7)
regular sexual partner at the last intercourse. Significant factors predicting extramarital sex included female gender (P = 0.025), age 15—49 years (P = 0.033), being currently married (P = 0.012) and polygamy (P = 0.023).
4. Discussion We did not collect the HIV serostatus of the participants in our study. However, based on over 4000 tests conducted by LMP, their HIV seropositivity rate was 15%.4 This is slightly higher than the average prevalence (12.1%) in the northern region reported by the Malawian DHS survey.6 In the current study, we found that a surprisingly high percentage of respondents had ever been HIV tested (70.3%) when compared with the Malawian national averages for rural areas (27.4% and 23.7% for men and women, respectively).6 Similarly, in a study of UN uniformed peacekeepers in Haiti, 94.7% of respondents reported having had an HIV test at some point in their life with, on average, 69.4% reporting that it had been voluntary.7 The uptake of HIV testing in our study, three-fold higher than the national average, is similar to results from Botswana (78%).8 The high uptake of HIV testing may be due to the aid provided by NGOs and the availability of ARV treatment at Likoma District Hospital since 2005, which may have increased the motivation of residents to be tested. In addition, with the district hospital successfully providing free HIV testing on the island, our findings agree with others that uptake of HIV testing can be expanded by removing structural barriers such as lack of access to free testing,9 inconvenient time,10 inconvenient location and distance,10,11 and shortage of counsellors.8
Awareness of HIV/AIDS prevention in Likoma Island, Malawi Table 6
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Crude and adjusted odds ratios for having been tested for HIV (n = 579)
Variable
% tested
Univariate analysis
Multivariate analysis
OR (95% CI)
AOR (95% CI)
Gender Male Female
65.5 72.0
1.0 1.4 (1.0—2.1)
1.0 1.7(1.1—2.6)a
Age group (years) 15—49 ≥50
73.4 56.5
2.0 (1.3—3.0)a 1.0
1.5 (0.9—2.5) 1.0
Education Below secondary school Secondary school or higher
67.9 75.7
1.0 1.4 (0.9—2.0)
1.0 1.4 (0.9—2.1)
Income-generating work Yes No
73.1 68.6
1.1 (0.8—1.6) 1.0
1.2 (0.8—1.8) 1.0
Marriage Never Currently Divorced/widowed
71.1 72.2 61.0
1.8 (1.1—3.1)a 1.7 (1.0—2.8)a 1.0
1.3 (0.7—2.2) 1.7 (0.9—3.2) 1.0
Polygamous marriage Yes No
89.5 66.4
2.8 (1.3—5.9)a 1.0
3.3 (1.5—7.0)a 1.0
OR: odds ratio; AOR: adjusted odds ratio. a P < 0.05.
As noted by the preliminary report of the 2004 MDHS,2 huge differences were observed between urban and rural areas in the proportion of young people (15—24 years) with complete knowledge of HIV/AIDS prevention methods, with more rural dwellers lacking such knowledge. The report speculated that the poorer knowledge of HIV prevention in females and rural inhabitants could be due to poor literacy among these groups and reduced access to HIV/AIDS education messages. In addition, the influence of strong cultural beliefs in rural areas may be a major barrier to people absorbing new information on HIV prevention. In the current study, the high education level of the respondents, the penetration of the Stepping Stones programme, free HIV testing services at Likoma District Hospital and the provision of community-based HIV testing counsellors were all positive factors that could have contributed to the residents’ greater knowledge of HIV/AIDS prevention than the national average. Nevertheless, the fact that Likoma Island is a small, isolated area with a discrete population could be another factor making information much easier to disseminate. By contrast, condom use and high-risk sexual activity in our study were at levels similar to national average data reported by the preliminary MDHS 2004.2 The influence of deeply rooted cultural factors could be a reason for the poorer result when compared with knowledge of HIV prevention. However, there are two other possible reasons. Firstly, HIV testing and ARV treatment were only introduced to the island 3 years and 2 years ago, respectively. Thus, observation of behaviour changes needs to be continued for a longer
period. Secondly, participants in our study were allowed to refuse to answer any questions they wished to. Therefore, there may be some bias in reporting of sexual behaviours in our study. Furthermore, regarding the distribution of condoms, Likoma District Hospital provided free condoms to people in post-VCT counselling, and 94.6% of people were aware of the availability of free condoms at the hospital (data not shown). Thus, the poorer utilization of condoms found in our study is not due to insufficient condom availability or accessibility. Some limitations in our study should be mentioned. Not all residents were available for interview when we visited their households and, although we attempted a second visit to those households, there may still be some self-selection involved. In requiring self-reporting of sexual partnerships and condom use there may be some reluctance to discuss private sexual behaviours, resulting in possible underreporting or misreporting. Participants in our study were allowed to refuse to answer questions if they wished. Therefore, there may have been some bias in reporting sexual behaviours in our study. The calculation of an appropriate sample size could avoid this in the future.7 In conclusion, with the aid of NGOs and ARV treatment provided by Likoma District Hospital since 2005, Malawi has successfully scaled up HIV testing in this remote island, and by doing so improved awareness of HIV/AIDS among the residents who accepted the test. The accessibility of condom use needs to be reinforced and enhanced, especially among those who have a regular sexual partner or practice polygamy.
890
Table 7
Multivariate logistic regression models for knowledge, attitudes and high-risk behaviour towards HIV/AIDS prevention
Variable
Ever received VCT services Female gender Age 15—49 years Secondary school or higher Currently married Income-generating employment Polygamyf
Complete knowledgea
Knew how to use correctly
Obtain a male condomb
Ever used male condom
Remain secretc
Used condom with regular partnerd
Extramarital sexe
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95%CI)
OR (95% CI)
2.4 (1.4—4.2)h 0.8 (0.4—1.6) 6.4 (3.4—12.1)h 1.8 (0.9—3.4) 2.7 (1.4—5.3)h 0.9 (0.5—1.7) 0.3 (0.2—0.7)h
0.9 (0.5—1.3) 0.6 (0.4—1.0)g 5.8 (3.1—11.0)h 1.3 (0.9—2.0) 0.9 (0.5—1.8) 1.4 (0.9—2.1) 1.0 (0.5—2.0)
1.0 (0.7—1.4) 1.6 (1.0—2.5)g 1.2 (0.7—2.1) 1.2 (0.8—1.7) 1.3 (0.7—2.2) 1.2 (0.8—1.7) 8.0 (3.3—19.5)h
1.7 (0.8—3.7) 0.9 (0.4—2.1) — 1.5 (0.7—3.0) 0.2 (0.0—0.7)g 2.3 (1.0—5.5) 2.1 (0.6—7.1)
0.7 (0.3—1.6) 0.3 (0.1—0.9)g 10.8 (1.2—96.3)g 1.3 (0.5—3.2) 0.2 (0.1—0.7)g 0.8 (0.3—2.1) 4.3 (1.2—14.9)g
1.5 1.0 1.5 1.7 1.9 0.9 0.7
(1.0—2.2)g (0.6—1.5) (0.9—2.5) (1.1—2.5)g (1.1—3.3)g (0.6—1.4) (0.4—1.2)
1.7 0.4 3.7 2.1 1.9 1.2 0.4
(1.2—2.6)h (0.2—0.6)h (2.1—6.5)h (1.4—3.2)h (1.0—3.4)g (0.8—1.9) (0.2—0.7)h
OR: odds ratio; VCT: voluntary HIV counselling and testing. Reference groups for variables in the table are never had VCT service; male; age ≥50 years; divorced/widowed; non-income generating work; non-polygamous marriage. a Subjects who knew at least two of three HIV prevention measures (condom use, faithful sexual partner and abstaining from sexual intercourse), rejected two common misconceptions about transmission (mosquito bite and touching infected person), and knew that a healthy-looking person can be HIV infected. b Subjects who knew of a place or person to obtain a male condom from. c Subjects who would want to keep a secret from anyone outside the family that one of their family members had AIDS. d Subjects who used a condom with regular sexual partner at last intercourse. e Subjects who had sex with non-marital, non-cohabiting partner in the last month. f Subjects reporting that they were married to more than one partner at once. g P < 0.05. h P < 0.01.
H.C. Chiang et al.
Awareness of HIV/AIDS prevention in Likoma Island, Malawi
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Authors’ contributions: HCC, KLY, CSL, YCK and PYC designed the study; KKG, MHM, TWY, YGN, SJH and YCW participated in the household interviews and data collection; CSL, YCK and PYC participated in the data interpretation; HCC, SFY and KLY performed the statistical analysis; HCC interpreted the statistical analysis; HCC and SFY drafted the manuscript. All authors read and commented on the manuscript and approved the final version. HCC is guarantor of the paper.
3. Helleringer S, Kohler HP. Sexual network structure and the spread of HIV in Africa: evidence from Likoma Island, Malawi. AIDS 2007;21:2323—32. 4. Canadian Physicians for Aid and Relief. Reducing the burden of HIV/AIDS in rural Malawi. Brief overview of the project. Toronto: CPAR; ©2002. http://www.cpar.ca/ countries.asp?page=malawiredaids [assessed 9 December, 2008]. 5. Amon J, Brown T, Hogle J, MacNeil J, Magnani R, Mills S, et al. Behavioral surveillance surveys: guidelines for repeated behavioral surveys in population at risk of HIV. Arlington: Family Health International; 2000. 6. Malawi HIV and AIDS monitoring and evaluation report, 2007: follow-up to the United Nations Declaration of Commitment on HIV and AIDS (UNGASS). Lilongwe, Malawi: Office of the President and Cabinet, Department of Nutrition, HIV and AIDS; 2007. 7. Elisabeth L, Megh G. HIV/AIDS knowledge, attitude and practice survey: UN uniformed peacekeepers in Haiti. New York, NY: United Nations, Peacekeeping Best Practices Section; 2007. http://www.peacekeepingbestpractices.unlb.org/PBPS/ [accessed 9 Library/KAP survey peacekeepers Haiti.pdf December 2008]. 8. Creek TL, Ntumy R, Seipone K, Smith M, Mogodi M, Smit M, et al. Successful introduction of routine opt-out HIV testing in antenatal care in Botswana. J Acquir Immune Defic Syndr 2007;45:102—7. 9. Nakanjako D, Kamya M, Daniel K, Mayanja-Kizza H, Freers J, Whalen C, et al. Acceptance of routine testing for HIV among adult patients at the medical emergency unit at a national referral hospital in Kampala, Uganda. AIDS Behav 2007;11:753—8. 10. Morin SF, Khumalo-Sakutukwa G, Charlebois ED, Routh J, Fritz K, Lane T. Removing barriers to knowing HIV status: same-day mobile HIV testing in Zimbabwe. J Acquir Immune Defic Syndr 2006;41:218—24. 11. Corbett EL, Dauya E, Matambo R, Cheung YB, Makamure B, Bassett MT, et al. Uptake of workplace HIV counselling and testing: a cluster-randomised trial in Zimbabwe. PLoS Med 2006;3:e238.
Acknowledgements: The authors wish to thank the local team members who helped us to coordinate all matters that made the study work smoothly. The Taiwan Medical Mission in Malawi commissioned the research and provided critical support throughout the study. Funding: The Ministry of Health, Taiwan, sponsored the travel and living expenses for members of Taiwan Students Without Borders during their stay on Likoma Island for 6 weeks. Conflicts of interest: None declared. Ethical approval: The research work was approved by the Taiwan Medical Mission in Malawi and the ethical committee of Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
References 1. Lake Malawi Projects. HIV/AIDS Programme: Aids With Us. Malawi Projects; ©2005. http://www.lakemalawiprojects.org/ projects.html [accessed 25 April 2008]. 2. Malawi Demographic and Health Survey 2004. Preliminary Report. Zomba, Malawi: National Statistical Office; 2005.