AIDS: A study of the knowledge, awareness and willingness to pay for VCT among students in tertiary institutions in Enugu State Nigeria

Health Policy 99 (2011) 277–284

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Voluntary counseling and testing (VCT) for HIV/AIDS: A study of the knowledge, awareness and willingness to pay for VCT among students in tertiary institutions in Enugu State Nigeria Benjamin Uzochukwu a,b,∗ , Nkolika Uguru b , Uche Ezeoke a , Obinna Onwujekwe b , Tochi Sibeudu c a b c

Department of Community Medicine, College of Medicine, University of Nigeria, P.O. Box 3295, Enugu, Nigeria Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria Department of Nursing Sciences, Nnamdi Azikiwe University Awka, Anambra State Nigeria

a r t i c l e

i n f o

Keywords: Awareness Voluntary counseling and testing Willingness to pay Nigeria

a b s t r a c t Objective: To examine the level of awareness of youths to voluntary counseling and testing and willingness to pay for this service, and to explore reasons for underutilization of this service. Methods: A cross sectional study was carried out among undergraduate students of two tertiary institutions in Enugu Nigeria using pre-tested interviewer administered questionnaire. Information was collected from 250 respondents per institution. Analysis was done using SPSS computer software package. Results: Most of the respondents (64%) have heard about VCT and 70.6% of the students obtained their information from the mass media (P < 0.05) while a minority (3.8%) heard from families. 76.6% of respondents believe VCT can provide useful information on HIV/AIDS and VCT is obtainable mainly in teaching hospitals (78.5%) and to a lesser extent in government hospitals (9.8%) and NGOs (8.8%), while being almost non existent in private hospitals (2.9%). 81% of the respondents did not attend VCT while only 19% attended. The reasons for non attendance were that majority of the students (45.7%) were unaware of the services (P < 0.05), indifferent to VCT (20.0%), (12.8%) felt it was costly and (13.3%) were afraid of discovering their HIV status. About 50% of the respondents were willing to pay for VCT and the mean willingness to pay was $3.2 (N370). Out of those willing to pay, 46% of them are willing to pay ($2.6) N300 while 34% and 20% are willing to pay $3.4 (N400) and $4.3 (N500), respectively (P < 0.05). Among those not willing to pay, 67.6% of them think it should be free (P < 0.05). Males and people with higher knowledge of VCT stated higher WTP values than females and those with less knowledge of VCT. Log OLS also showed that a higher level in the University was positively related to WTP. Conclusion: The high knowledge of VCT does not reflect on the attendance at VCT clinics. Respondents seem ignorant about where the services can be obtained and they believe VCT should be free or adequately subsidized. The cost of VCT is much higher than the mean WTP and governments should take this into consideration when subsidies are being considered. More VCT centers should be created and widely publicized in various communities. © 2010 Elsevier Ireland Ltd. All rights reserved.

∗ Corresponding author at: Department of Community Medicine, College of Medicine, University of Nigeria, P.O. Box 3295, Enugu, Nigeria. Tel.: +234 42 259609; fax: +234 42 259569. E-mail address: [email protected] (B. Uzochukwu). 0168-8510/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2010.11.007

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1. Introduction HIV/AIDS has become a major public health problem especially in sub-Saharan African, which has the highest burden, constituting almost 70% of people living with it worldwide [1]. As at 2008 the world estimate of people living with HIV/AIDS was about 33.4 million [2]. Nigeria has been hard hit by the HIV/AIDS epidemic, with an estimated adult HIV prevalence of around 3.1%, [3] and globally ranking third only to India and South Africa [4]. An estimated 4.3 million Nigerians are living with the HIV virus [3], comprising of 2.9 million adults (with 15–19.4% of this representing the youths) [3,5,6]. The epidemic in Nigeria has been classified as generalized with estimates showing that 220,000 children under the age of 15 are living with HIV [7], while about 1.3 million children have been orphaned by the disease [3]. The epidemic which reached its peak in 2001 at 5.8%, has declined in recent years from 4.4% in 2005 to 3.1% in 2007 [1,2], though part of this observed decline can be attributed to an increase in the number of deaths recorded. However, many more Nigerians are expected to die as the majority of HIV infected people move from an initial infection to full blown AIDs without a commensurate expansion in the treatment programs provided. In such a scenario, the Federal Ministry of Health estimates that by 2010 there will be up to 2.8 million cumulative deaths recorded [8]. Voluntary counseling and testing (VCT) for HIV is internationally recognized as an effective and important strategy for both prevention and care [9,10]. Thus it is said to be a gateway to prevention and treatment, and an essential tool in the control of HIV/AIDS epidemic [2,9]. These findings have boosted interest and support for VCT as a valuable component of comprehensive HIV/AIDS programming [10]. HIV testing and counseling is a direct, personalized and person-centered intervention, tailored to prevent transmission and obtain referral to additional medical care, preventive, psychosocial and other needed services in order to remain healthy [11]. Counseling was designed to help persons interpret the meaning of negative or positive antibody results, to initiate and sustain behavioural changes that reduce risk of becoming infected and to assist HIV positive individuals in avoiding infecting others [5,11,12]. Thus VCT can be described as a critical component of preventive strategies to reduce transmission of HIV/AIDS from mother to child and it has become one of the most common means of preventing, detecting, and improving access to care and support for HIV/AIDS [13]. Over the past 20 years, VCT have helped millions of people learn their HIV status, yet more than 80% of people living with HIV in low and middle-income countries do not know that they are infected [14]. In order to reduce the growth and size of the epidemic at population level, efforts are urgently needed to increase the provision of HIV testing through a wider range of effective and safe options, since antiretroviral drugs are not curative, and are accessible only to a privileged minority of the world’s population. WHO interventions focus on key areas such as: testing and counseling as the entry point to both treatment and prevention; comprehensive programmes to prevent HIV/AIDS infection among women, infants and young

children and target interventions for vulnerable groups including sex workers and people living with HIV/AIDS [9,15]. Therefore, it has been suggested that an effective VCT programme should begin by raising community awareness on the benefits of the testing and counseling, both in preventing the spread of the infection and meeting the need for care and support in communities [2]. Recent studies indicate that overall coverage of testing and counseling is extremely poor in countries with very high HIV/AIDS burden, and worldwide, only 5% of people with HIV/AIDS are estimated to be aware of their status [9]. Therefore, access to testing and counseling is the key for successful implementation of antiretroviral therapy and avoidance of re-infection and transmission through behavioural change [9]. However, HIV VCT is not available in most regions in Africa and a few studies have described barriers to HIV testing in sub-Saharan Africa [15–17]. These studies are particularly related to disclosure of HIV/AIDS status to sexual partners, therefore increasing the fears of VCT attendance due to stigma and discrimination [15,17–19]. In addition it was also observed that only 0.2% of adults in low and middle income countries received voluntary HIV counseling and testing services due to lack of access to treatment [18]. In many low and middle income countries, access to services and treatment is generally low [3]. Despite the high risks, only 9% of men and women of reproductive age had been tested for HIV and received results in the 12 months prior to a 2005 nationwide survey whereas only 17% of individuals with advanced HIV infection were receiving antiretroviral therapy [3]. In Nigeria, the gross under usage of VCT necessitated a voluntary confidential counseling and testing campaign in December 2006 in Abuja [20] in order to increase awareness of VCT. This took into consideration the fact that the National Action committee on AIDS (NACA) reported that about 17,328 clients participated in various VCT services between January and March 2005 in Nigeria with the percentage of youth participation being 24.3% [21], showing the poor utilization rate among Nigerian youths. A lot of challenges have been overcome in order to institute VCT in Nigeria one of which is the stigma and discrimination surrounding HIV issues, including the dearth of properly trained HIV counselors in Nigeria [22]. Inhibitors of youth friendly VCT services include issues of transportation to the centers, hours of operation and confidentiality [23]. Also, some studies observed that youths are encouraged to be tested, only to be inhibited by VCT services staff that have moralistic attitudes regarding sexually active youths [23]. In addition lack of access to tailor made counseling programmes, poverty, alcoholic addiction and drug use were held responsible for hindering the usage of VCT services among youths [24]. A study on attitudes towards HIV testing and VCT among university students in four African countries namely Nigeria, South Africa, Uganda and Zimbabwe found that only 17.3% of the students had ever attended VCT service [25]. That VCT is an important step in the development of a comprehensive package of HIV/AIDS services cannot be over emphasized; it is an effective strategy in reducing

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risk behaviour among individuals at risk for HIV/AIDS [26]. Research has shown that VCT is a cost effective intervention in high prevalence settings and it motivates positive behaviour change among both HIV positive and negative persons [26]. VCT can therefore be said to be the setting of information exchanges between the provider and a client. It helps the individual to reach appropriate decision and act on it [27]. The counseling is supposed to include a discussion of medical and lifestyle issues grounded on individual’s concerns, fears and values related to reproductive and sexual health [27]. Individual perceptions towards VCT are shaped by cultural values, opinions about the role of health system and the nature of interactions with providers [27]. Addressing clients’ perceptions of VCT is crucial to improving their satisfaction and health outcomes, helping a continued and sustained use of services [11,28]. VCT is a cost effective means of addressing the HIV AIDS situation especially in resource poor countries with a heavy HIV load. The effectiveness of this aspect of HIV AIDS control package is influenced by the cost of VCT, hence the willingness to pay for the service [29]. For example the cost of providing counseling and testing to each client in Kenya ($27) and in Tanzania ($29) was relatively high for countries where per capita health expenditures do not exceed $10 [29]. Similarly a study done in Nigeria among female sex workers (FSW) showed that majority of these FSWs admit willingness to pay for VCT services if the charges are minimal and affordable and also 71% of them expressed their willingness to pay if they were HIV positive [30]. The cost of anti retroviral drugs are high, and given that majority of Nigerians are living on less than $2 a day, only the wealthy minority are able to afford the treatment [31]. Nevertheless, the study indicates that many HIV positive individuals may be willing to pay for the treatment [32]. Thus willingness to pay (WTP) can be said to be the maximum amount of income an individual is willing to give up in order to ensure that a proposed service or good is available [33]. It can be used to monetize benefits people derive from or associated with services rendered. WTP or demand elicited using the contingent valuation method (CVM) in welfare economics is the theoretically correct method for determining demand through the value that people attach to goods and services [34,35]. In sub-Saharan Africa the CVM approach has been used most often to understand the demand and set prices for goods and services [36] unlike in high income countries where CVM is used mostly for generating the monetary values consumers place on goods and services for cost benefit analysis [37,38]. However, the validity of CVM has often been criticized because it is based on a hypothetical market in which respondents are not actually required to make the contributions they claim to be willing to pay because hypothetical donations have been found to significantly exceed real donations unless respondents that actually responded were very certain of their response and stuck by it [39–41]. In order to improve the reliability and validity of CVM, a more realistic scenario is created by specifying the item to be valued, describing the contingent market, explaining method of payment and selecting questionnaire formats for eliciting values [42]. However, previous studies observed that the discrepancy between hypothetical and actual CVM

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valuations is smaller when the commodity is very important to the consumer [43]. Therefore, since WTP is influenced by the ability to pay [18], it is important to examine the extent to which different groups of people are willing to pay for VCT services so as to inform health policies and resource allocations in developing countries for all aspects of HIV AIDS management. This study was embarked upon because the youths, students of tertiary institutions included, constitute a significant proportion of persons affected by the disease and a good number of them are also sexually active. In 2005, among a nationally representative sample of nevermarried Nigerian adolescents more than 25% were sexually experienced [44] and in 2006, SFH/Nigeria found that only 66% of male out of school youth had used a condom at the last sexual encounter [45]. Knowing the benefits of VCT, it is important to determine their awareness and utilization of VCT services, willingness to undergo and pay for VCT and factors that hinder utilization of these services. 2. Method 2.1. Study area This study took place in Enugu State Nigeria which has a population of 3,257,298 [46], and was carved out of the old Anambra State. Enugu State is surrounded by six states. It borders Abia and Imo States in the South, and is flanked in the east and west by Ebonyi and Anambra states, respectively and in the north by Kogi and Benue states. The state lies partly within the tropical rain forest belt to the south. The native population is entirely Igbo with a sprinkling of Igala near her borders with Kogi state. Other ethnic groups are however well represented in the state with a predominance of Hausa and Yoruba communities. The state is well known for its industrial centers and markets. The study was conducted at the University of Nigeria, Enugu campus (UNEC), and the Institute of Management and Technology (IMT) Enugu. The University of Nigeria has two campuses with the main campus located at Nsukka in Enugu State, while the other campus is in Enugu the capital city of Enugu State, Nigeria. The Enugu campus is located in Ogui New Layout. Its boundary on the Southwest is the Enugu Port-Harcourt railway line, on the East is the Maryland Township and on the North is the Enugu State University of Technology (ESUT) and the women training college (WTC). There are 4 male and 4 female undergraduate hostels in the campus. The total population is estimated at 10,000 at the time of study with about 7000 students resident on campus. Presently there are 6 faculties in the University of Nigeria Enugu Campus. The students are of varying nationalities and tribes but mostly Nigerians of the Igbo extraction. The institute of management and technology (IMT) is a state polytechnic in Enugu State, and has two campuses, namely campus 2 and campus 3. Campus 2 is located at the Polo park of the Government residential area (GRA) and only contains a female hostel within it. Campus 3 is located at Independence layout and shares a common boundary with The Enugu State University of Technology and UNEC. It has 2 male hostels within it.

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2.2. Study design A cross-sectional study was carried out in two tertiary institutions in Enugu State namely UNEC and IMT using pre-tested interviewer administered questionnaire as a study tool. 2.2.1. Sampling and sample size The tertiary institutions in Enugu State, which were used as the sampling frame were stratified into Universities and Polytechnics (4 Universities and 2 Polytechnics). The sampling technique used was the probability sampling method so that every member of the study area would have an equal chance of being selected. The two tertiary institutions used in the study (UNEC and IMT) were selected by simple random sampling and in each Institution, each faculty and department used was selected by simple random sampling. From each department two different classes were selected also by simple random sampling which was now used as the sample population. The sample size was then calculated using prevalence of VCT of 17.3% [25], a power of 80% and sampling error of 0.05 at 95% confidence limit to get 220 respondents per institution, giving a total of 440 for both institutions. Some allowance was given for anticipated non-response cases and this was increased to a total of 500 (250 for each school). 2.3. Data collection The instrument used for data collection was a self administered, pre-tested questionnaire on the Knowledge of VCT, willingness to undergo VCT and willingness to pay for VCT. This data was obtained after an informed consent form was signed by the respondents. The questionnaires were distributed randomly within a set of number tags bearing numbers 1–100 given to students in all the classes involved in the study. The questionnaires were also collected on the same day. In order to elicit the WTP for VCT, the bidding game questioning format was used. The respondents were presented with a first bid where the respondent had a choice of either yes or no. Depending on the answer, the respondent was presented two other bids after which he or she was now asked an open ended question of how much they were willing to pay (open ended question). Using the predetermined bidding iteration, the bid was lowered or raised depending on the respondents answer. The process went on till the maximum WTP was reached. The estimate for the starting bid was gotten from private clinics as the public health facilities and missionary hospitals in the state do not charge for VCT. The data from the two institutions were collapsed for analysis, and data analysis was done using SPSS computer software package. 2.4. Data analysis Data were analysed using Statistical Package for Social Sciences (SPSS) version 11.0 for frequencies, and ChiSquared test and statistical significance set at P < 0.05. Log

ordinary least squares (OLS) were used to determine the validity of elicited WTP where WTP was the dependent variable and a number of variables that could explain WTP were the independent variables. 2.5. Ethical approval This research was approved by the Medical Research Ethics Committee, University of Nigeria Teaching Hospital, Enugu. Individual written informed consent was obtained from all participants prior to the interview following a verbal and written explanation of study aims and procedures. 3. Results 3.1. Socio-demographic characteristics of the respondents Table 1 shows that a total of 500 students drawn from the two schools participated in the study. It also shows that the age group 20–24 years constituted the majority of the respondents, followed by the age group 25–29 years. Also a majority of the respondents were females and a majority in their second year in the schools. About 92.4% were single, 6.8% married and 0.4% separated and divorced, respectively. 3.2. Awareness and knowledge of VCT services among the respondents As shown in Table 2, most of the respondents (64%) have a good level of knowledge of VCT, (P < 0.05) while a lower percentage (34.6%) have not heard of VCT. The majority of the respondents (70.6%) obtained information about VCT

Table 1 Socio-demographic characteristics of respondents. Variables Age 15–19 20–24 25–29 30–34 35–39 Sex Male Female Marital Status Single Married Separated Divorced Respondents’ institution n = 500 University of Nigeria Enugu Campus Institute of Management and Technology Class level 100 level 200 level 300 level 400 level

Frequency

Percentage

17 338 133 9 3

3.4 67.6 26.6 1.8 0.6

242 258

48.4 51.6

462 34 2 2

92.4 6.8 0.4 0.4

250

50.0

250

50.0

91 154 120 135

18.2 30.8 24.0 27.0

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Table 2 Awareness and knowledge of VCT services among the respondents. Variables Awareness of VCCT n = 500 Have heard Not heard Not sure Source of information n = 320 The electronic mass media Friends Family Journals/newspaper Health institution Knowledge of where to obtain VCT n = 320 Yes No Centers where to obtain VCCT n = 102 Teaching hospital (UNTH) Non governmental organization Private hospital Other government hospitals

Frequency

Percent

P-value

320 173 7

64.0 34.6 1.4

0.001

226 43 12 18 21

70.6 13.4 3.8 5.6 6.6

0.001

98 222

30.6 69.4

0.001

80 9 3 10

78.5 8.8 2.9 9.8

0.001

from the mass media (P < 0.05), a smaller percentage from friends and very little information was obtained from the family (3.8%). Knowledge of where VCT services can be obtained and number of people that access the different centers where it can be obtained can also be seen in Table 1 which shows that a greater percentage of the students (69.4%) do not know where to obtain VCT services (P < 0.05) while a minority (30.6%) knew where to obtain these services. 3.3. Attendance to VCT services and reasons for non attendance

3.4. Perceptions of students about paying for VCT Table 4 shows that 50% of the respondents were willing to pay for VCT while 50% were not. 46% of this proportion were willing to pay N300 while 34% and 20% were willing to pay N400 and N500, respectively. The table also shows that majority (67.6%) of those not willing to pay for VCT think it should be free (P < 0.05) and 9.8% said the test was not necessary. The mean amount they are willing to pay is N370 while the median amount they are willing to pay is N300. 3.5. OLS regression analysis

Table 3 shows that 81% of the respondents have not been to any VCT center and (45.7%) of these had not attended any VCT program because they did not know where these services were offered (P < 0.05), (20.0%) did not attend because they were indifferent, 12.8% because of the cost of the service and 8.1% due to stigmatization. (Some respondents gave multiple answers). Only about 19% had attended a VCT clinic and among these, more than half (53%) were males and there was no statistical difference in VCT attendance among the sexes.

Table 5 shows the results of the OLS regressions for WTP for the respondents. WTP was positively related to knowledge of VCT. Also there was a positive relationship of sex with WTP, implying higher WTP amongst males compared with females. Additionally, the higher the number of years in the university, the higher were the amounts of elicited WTP. The regressions were statistically significant and explained 17% of the variations observed in WTP for respondents.

Table 3 Attendance to VCT services and reasons for non attendance. Variable Attendance to VCT Service (n = 500) Attended Not attended Sex of VCT attendees (n = 95) Male Female Reason for not undergoing VCT (n = 405) I was not aware of VCT service I am indifferent I am afraid to discover my HIV status It is too costly Because of the stigma if I’m positive Willingness to undergo VCT (n = 500) Willing Not willing

Frequency

Percentage

Chi-square for trend

P-value

95 405

19.0 81.0

153.683

0.001

53 42

55.8 44.2

185 81 54 52 33

45.7 20.0 13.3 12.8 8.1

307 193

61.4 38.6

2.55

0.110

171.04

0.001

9.68

0.002

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Table 4 Perceptions of students and WTP for VCT. Variable Willingness to pay for VCT Willing Not willing Total Amount respondents are WTP N500 N400 N300 Total Reasons for not WTP n = 256 The test is not necessary It should be free I don’t have the funds for it I am busy

Frequency

Percentage

250 250 500

50 50 100

49 86 115 250

20 34 46 100

25 173 52 6

9.8 67.6 20.3 2.3

Chi-square for trend

0.00

P-value

1.0

39.152

0.001

32.972

0.001

Mean WTP: N370 ($2.5), Median WTP: N300 ($2), Exchange rate: N150 to $1.

Table 5 Reduced log ordinary least squares model of willingness to pay (WTP) for Voluntary counseling and testing (VCT). Independent variables

Reduced model coefficient (SE)

Age Sex Level in the university Knowledge of VCT F statistics Adjusted R2

0.07 (0.19) 0.18 (0.05)** 0.14(0.03)** 0.09 (0.02)** 8.36** 0.18

**

P < 0.05.

4. Discussion Most of the respondents have heard about VCT and acknowledge it as a useful way of fighting HIV/AIDS. However, majority of them do not know where to obtain these services. Our study shows that the majority of the respondents acquired their knowledge of VCT from the mass media. This could account for the high level of knowledge about VCT among the youths since a great number of them listen to the radio or watch television. However, very little information was obtained from family sources an indication that parents may not be aware of these services or discussions about HIV/AIDS or VCT is generally viewed as inappropriate in family settings and so they are unable to impart any information to their children. The media though seems to be a much better avenue of getting this message to the youths because most of the students knew that VCT was a means of fighting HIV/AIDS and that it can help in early detection of HIV positive individuals [36]. This statement corroborates the findings in a study done by USAID/REDSO which found that VCT is an effective strategy for reducing risk behaviour among individuals at risk for HIV/AIDS and it motivates a positive behaviour change among both HIV positive and negative persons [26]. The results of this study are also similar to an earlier study in southeast Nigeria among polytechnic students [47] that showed a majority of the students had knowledge of VCT with the mass media and Churches being the highest sources of information on VCT. Similarly, most of the students did not know where VCT services could be obtained.

Awareness of where to access VCT services has proved a problem for the students. From our study we find that although knowledge of VCT is high, it does not reflect on the attendance at the clinics and this can be attributed to the fact that majority of the students do not know where to obtain these services. Probably because enough information has not been dispersed as to where the VCT centers can be found or that there are not enough VCT centers in the country. It was observed that information on VCT from health institutions was very low where ideally they should be able to offer good information as to where and when the services can be obtained. Poor or improper dissemination of information will make accessing these services difficult for the students. The low usage of VCT is also worrisome because most of the respondents were single and in the southeast Nigeria where there are reasonable number of Christians of catholic faith, VCT is compulsory before wedding in the church. So the students will need to resolve this low usage before marrying. Considering the amount of awareness campaigns that has been mounted over the years on the need for VCT, utilization of VCT services of 19% is poor in this study, a result which is quite similar to a study conducted seven years ago among university students in four African countries namely Nigeria, South Africa, Uganda and Zimbabwe where VCT usage was found to be only 17.3% [25] and another that was conducted in southeast Nigeria [47] where less than a third of the students had taken an HIV test at one time or the other. In Kenya, a community survey also indicated that only very few people had received VCT although the participants expressed readiness to have VCT [48]. This poor utilization of services in all the settings can be looked at under the Anderson and Newman healthcare utilization model which states that utilization of healthcare services usually depend on predisposing enabling and need factors [49]. It encompasses ones health beliefs and health seeking behaviour, cultural beliefs, social networks, income, perceived health status and severity of disease [49]. Therefore if an individual perceives himself not to be at risk of HIV possibly due to lifestyle, or does not have a social network which is supportive of VCT, going for VCT might not be considered essential by such a person.

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Other factors that have contributed to the underutilization of VCT are indifference, fear of discovering ones’ HIV status, and the stigma associated with being found positive, and cost of the test. These findings are similar to earlier findings in Nigeria among adult population [50] where a majority were willing to have VCT. However, misconceptions, fear, gaps in knowledge and limited access to VCT remain prevalent and fear of stigma, marital disharmony, incurable nature of the disease and cost of treatment were among the reasons for rejection of VCT. The fear of stigma and discrimination has been described as a barrier to HIV testing in sub-Saharan Africa, this is usually found in relation to fear of disclosure of HIV/AIDS status to sexual partners, to community or family members and also discrimination from the medical personnel handling the counseling services [17–19]. In addition to the above mentioned study, lack of access to tailor-made counseling programmes, poverty, alcoholic addiction and drug use were found to be responsible for hindering the usage of VCT services among youths [24]. Although alcoholic addiction and drug use were not found to be implicated in underutilization of VCT in our study, youth friendly voluntary counseling and testing services are probably not readily available. Indifference to VCT could stem from the fact that although most of these students have heard about VCT, they probably do not believe they can contract HIV/AIDS because they do not have a lifestyle which puts them at risk of contracting HIV/AIDS. VCT services are a problem with the students because from the results a large number of them stated that the service was too costly and should be made free. Most of the respondents were not willing to pay the stipulated amount in the state but would be willing to pay less. The most laudable explanation for this could be that the students do not feel the test is really necessary, possibly because they have not factored in VCT services or any form of preventive medicine into whatever stipend they get from their guardians making it difficult for them to pay. Another fact is that the parents do not advice their children on VCT, most likely because they are ignorant of it, and so they would probably not see the relevance of giving their wards money for this service. Currently the market price of VCT gotten from private laboratories and clinics in Enugu State is about N500 ($3.3) and our study shows that this is higher than N370 ($2.5) which is the maximum amount the students are willing to pay. This high market price seems to be a factor in the low utilization of VCT among the study population. Although the preferred choice is that VCT should be free as shown by our results where most of the respondents refused to pay because they believe it should be free. It also seems that because one is not ill when accessing these services the students do not feel they should part with their money and so want government to offer it free in all clinics for the youths. This is buttressed in a study which showed that although the costs of antiretroviral (ARV) drugs are high, HIV positive individuals are willing to pay for the (ARV) treatment [30]. In Nigeria, VCT is free in public health facilities when available. But this is not so in private clinics and laboratories and a study in Kenya [48] has shown that respondents

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preferred private doctors’ offices as testing facilities. Even in the public health facilities where VCT is free, there is also transport costs associated with visiting VCT centers. It is therefore necessary to make VCT readily available at no cost in all public and private facilities. The mean WTP is half of the costs of the VCT, and ordinarily one would say that VCT should be cancelled. However, HIV is a contagious disease and there is therefore an external effect of testing and counseling since it prevents further spreading of the disease. In effect the social benefits of the disease were not captured by the individual respondents valuation, but the WTP result which was elicited using CVM can be used to understand demand for VCT and help determine a level of subsidy for VCT needed to cover the costs [36]. Another major consideration is that the services were found to be unaffordable for most of the students. This on its own will decrease the rate of utilization of these services thereby increasing the chances of contracting the disease and worsening the HIV/AIDS situation in the country. The result also showed that males stated higher WTP amounts than females. This could be due to the fact that in our culture, naturally females expect that males will always pay for them in all things including health. Males may also get involved in small scale businesses to make more money as students and therefore there might be an income effect as they will now generally earn more than females. However, the positive association of knowledge of VCT with WTP for VCT implies that the more knowledgeable respondents may be more aware of the importance of VCT and thus value it more and ready to pay for it. Also the positive association of class level in the University with WTP could be due to the fact that the more years they spent in the University, the more they are exposed to information on VCT which also could be linked to knowledge of VCT. 4.1. The limitations of this study This study was conducted with only students so it might be difficult to extrapolate the results to the general population. However, this study has set a base on which future studies can be built in which the different population groups can be researched. We did not capture socio-economic characteristics of the respondents during the survey which would have enabled us to run a regression analysis of what socio-economic variables explains WTP, knowledge and awareness. We therefore acknowledge this as a limitation of the study. However, some of the socio-demographic characteristics explain WTP for VCT. 5. Conclusion and recommendations The knowledge of VCT for HIV/AIDS among youths in tertiary institutions in Enugu State is adequate. However, the awareness of where these services are rendered seemed to be an issue, so also is the cost of VCT which all contribute to the underutilization of these services. To improve the utilization of these services it is important that the service should be subsidized or free in all health facilities for youths to enable them access this service freely. The VCT centers should be widely publicized and every infor-

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