Keywords

Predictors; HIV testing; Youth; Cameroon; Gabon

Introduction

HIV testing is believed to be a cornerstone in the prevention and reduction of the HIV epidemic and is a critical measure for HIV prevention programs and services [1,2] as the major sources of HIV transmission are people living with HIV/AIDS who have not yet tested and don’t know their serostatus but yet continue to have unprotected sex [3]. A study based on a mathematical model suggested that a massive coverage of HIV testing coupled with immediate initiation of anti-retroviral treatments (ART) might help to halt the HIV epidemic [4]. Additionally, it is a rapid and cost-effective intervention and the only means to know the HIVstatus of an individual and thereby to seek medical support early and to facilitate referral for social support [5-7]. Knowing the serostatus of the youth also helps them to change their risk sexual behavior [7] and to increase the use of condom as a prevention method even among people in a stable relationship [8]. Through HIV testing, both the HIV-negative and positive individuals can be benefited. The HIV-negative people get updated information on the primary prevention from the pre- and post-test counseling and the HIV-positive people get the opportunity of accessing to the psychosocial support, linkage to care and treatment [2]. On the other hand, delay in diagnosis of HIV infection is the most substantial obstacle to accelerate HIV treatment and prevention and increases morbidity, mortality, and health care costs [9]. The main objectives of the Joint United Nations Program on HIV/AIDS (UNAIDS) are to make voluntary HIV testing services 90% accessible to help 90% of people living with HIV to know their status, especially young people and those living in a high HIV prevalent settings [10,11]. However, even though progress has been made in establishing HIV testing centers, there is a huge gap between the targeted objective and the findings on the ground that “19 million of the 35 million people living with HIV globally do not know their HIV-positive status” [12] which points out the urgency of closing the testing gap [10]. As many other countries [1,13,14], the HIV test uptake in Cameroon and Gabon found to be low [15,16]. In Cameroon, the trend of HIV testing in the general population was decreased from 573,897 in 2007 to 538,252 in 2013 [17]. In fact, there is lack of information about the HIV test experiences of youth in particular. HIV testing remains as a strategic intervention to prevent transmission and stop the epidemic especially in countries with high HIV prevalence. Of all the Western African countries, Cameroon was the first highly HIV prevalent country followed by Gabon in 2014 [3,4]. In spite of the decrease of the new infection by 41% in sub- Saharan Africa between 2000 and 2014, the prevalence of HIV/ AIDS has increased from 4.3% in 2011 to 4.8% in Cameroon, and a minimal decrease in Gabon from 4.1% in 2012 to 3.9% in 2014 [18-22]. Globally, youth are particularly affected by HIV and half of the new infections are among 15-24 years old youth [23,24]. Worldwide new HIV infection among youth in 2010 was 42% out of which 80% were living in sub-Saharan Africa [25]. Based on the world Health Organization (WHO) report, every day 6000 youth are infected with HIV [26]. Hence, the number of AIDS-related deaths among youth increased by 50% between 2005 and 2012 [27]. More specifically, in Cameroon, 2.7% of young women and 0.5% of young men were living with HIV in 2011 [17] and in Gabon it was 1.5% of youth in 2012 [16]. In this regard, UNAIDS in its program, the fragile window of opportunity to fast-track the AIDS response ‘2016 to 2020', has identified Gabon with the countries that need a focused action and Cameroon among the 35 countries in which special focus and scaled up efforts are needed [28]. Advancing HIV test centers and making them more accessible and visible encourages HIV testing uptake among youth. Moreover, understanding of the determining factors to predict HIV testing is the cornerstone to advance the coverage of HIV testing thereby to control the HIV transmission [2,3]. Studies from other countries revealed that age, type of residence, education, marital status, HIV-related stigma, occupation, low socioeconomic status, and HIV/AIDS knowledge as the main determining factors to predict HIV testing [1,2,13,14,29-32]. However, to our knowledge, no study has been done to investigate the predictors of HIV test among Gabonese and Cameroonian youth. Similarly, in Gabon, lack of studies on the epidemic focused on specific groups was underlined as one of the main challenges on the national report on the response to HIV/AIDS in 2014 [16]. Therefore, the aims of this study were to investigate the HIV testing experiences and to explore its predicting factors among 15-24 aged Cameroonian and Gabonese youth.

Method and Design

Data source

This study used DHS data conducted in Cameroon (2011) and Gabon (2012) which are the most recently available DHS data on the two countries as of June 2016 [33]. The DHS is a nationally representative household survey, which collects data on a wide range of health indicators including HIV/AIDS. It is conducted based on multistage cluster sampling method and by probability proportional to size which enables us to generate a nationally representative sample. First, geographic units commonly known as primary sample units (PSU) are sampled within the country, and then a random sample of households are selected with a known probability. Interviews are conducted with all women aged 15-49 and men 15 -59 who spent the previous night in the household. During the collection of data, interviewers use a standardized questionnaire to gather information from participants in each country, providing an internationally accepted, comparable and consistent data among countries [34]. The data collection method in DHS is defined and published elsewhere [34-37]. In this study, nationally representative sample of 14,880 youth 15-24 years old selected by probability proportional to size was filtered from the DHS data files of the two countries. Selection of the countries was determined by being the most HIV prevalent West African countries. Variables of HIV test were selected and re-categorized based on the MEASURE DHS online tools for HIV/ AIDS survey indicators database [37].

Measures

Independent variables

The explanatory variables of the survey respondents like the level of education, place of residence, and wealth index were taken as they appeared in the DHS data files. The study used only the first two age groups, 15-19 and 20-24 from the seven 5-year groups created in the data files. Marital status was re-categorized into three: never in union, currently in union (married and living with a partner), and formerly in union (widowed, divorced and separated or no longer living together). Religion of the respondents was grouped into categories which varied between the two countries. Hence, it was recoded into four groups: ‘Christian’- (Catholic, Protestant, Methodist, Evangelical and other Christians), ‘Muslim’, ‘other religion’ - (Animist and other religions) and ‘no religion’. The various categories of occupation in the two countries were re-grouped to working (involving in different works) and not working.

Definition of dependent variables

Voluntary HIV Counseling and Testing (VCT) is defined as the way to make an informed choice to know an individuals’ HIV-status and to take suitable action through confidential counseling [1]. In this context, in the present study respondents were assessed whether they know a place to get HIV test, ever been tested in their lifetime, tested in the last 12 months, and tested and received results in the last 12 months. All the variables were binary variable containing a “YES” or “NO” answers, coded 0 if the answer is “NO” and 1 otherwise.

Statistical Analysis

The study used SPSS version 22 to analyze the DHS data. Binary logistic regression was used for multivariate analysis to examine the significance of the HIV test variables against the selected factors to predict HIV test among youth. Odds ratio and 95 percent confidence interval were used to observe the associations and comparisons by taking p-values less than 0.05 as significant. In every part of the analysis, missed values were not considered.

Ethical consideration

The DHS survey is approved by the Institutional Review Board of ICF Macro in Calverton, Maryland, USA. In all countries, DHS study participants give informed consent before participation and all information is collected confidentially by removing all the identifiers of the participants. Permission for use of the raw data in the present study has been obtained from ICF Macro Inc. in Calverton, Maryland, USA.

Results

Characteristics of the respondents

Socio-demographic characteristics of the survey respondents are presented in Table 1. A total of 14,880 youth aged 15-24 years; 4765 (32.0%) males and 10,115 (68.0%) females were included. The mean age of the respondents’ was 19.15±2.82 years. The majority were from urban, secondary in education, Christianity in religion and never in union in marital status. In Cameroon, an increasing pattern of percentages was observed with increase of wealth index from the poorest to the richest, whereas, the opposite was seen in Gabon.

Table 1: Socio demographic characteristics of participants.

History of HIV test experiences among youth

The HIV test experiences of youth are presented in Figure 1. Above 14% of Cameroonian youth (14.3% of males and 14.1% of females), and 19% of Gabonese youth (female=16% and males 25.4%) did not know where to get HIV test. In Cameroon, 23.1% of youth (22.2% of females and 25.3% of males) and in Gabon 41.6% of youth (53.2% of females and 21.5% of males) were tested for HIV in their lifetime. However, only 11.7% of Cameroonian (11% of females and 13.6% of males) and 25.9% of Gabonese (33% of females and 13.55% males) youth were tested for HIV in the previous 12 months. Most of the youth tested for HIV in the last 12 months, 86.5% of Cameroonian and 95.5% of Gabonese youth, received results of their HIV test. The main reasons for HIV test among Cameroonian youth were asked for the test (46.9%), offered and accepted (4070%) and required (124.4%). However, this type of data was not available in the DHS data files of Gabon.

Figure 1: HIV test experiences of the respondents.

Comparison by country and gender

Comparisons of HIV testing by country are shown in Table 2. Gabonese male (AOR=0.47, p<0.001) and female (AOR=0.64, p<0.001) youth were less likely to know a place where to get HIV test compared to Cameroonian youth. However, Gabonese youth were more likely to be tested for HIV in their lifetime (females AOR=1.44, p<0.001), in the last 12 months (males AOR=1.31, p=0.014 and females AOR=1.65, p<0.001) and to be tested and received results (males AOR=1.37, p=0.005 and females AOR= 1.65, p<0.001) than Cameroonian youth. Lifelong HIV test experience among males was not statistically significant. Comparison of HIV testing by gender is presented in Table 3. Males were less likely to know a place where to get HIV test (Cameroonian AOR=0.76, p=0.008 and Gabonese AOR=0.61, p<0.001), ever been tested for HIV (Cameroonian AOR=0.36, p<0.001 and Gabonese AOR=0.23, p<0.001), to be tested in the last 12 months (Cameroonian AOR=0.56, p<0.001 and Gabonese AOR=0.33, p<0.001), and tested and received results in the last 12 months (Cameroonian AOR=0.54, p<0.001 and Gabonese AOR=0.33, p<0.001) than female youth in both countries.

Table 2: Multivariate analysis showing Comparison of HIV testing by country.

Table 3: Multivariate analysis showing Comparison of HIV testing by Gender.

Multivariate analysis of the predicting factors of HIV test among youth

Knowledge of youth to a place where to get HIV test

Table 4 presents the multivariate analysis of knowledge of youth to a place where to get HIV test. The 20-24 aged youth and urban residents of both countries and both gender groups were more likely to know a place to get HIV test than their 15-19 age group counterparts and rural residents, respectively. An increased adjusted odds ratio (AOR) of knowing a place to get HIV test was observed with increased educational status from primary to higher than youth with no education in both countries. Regarding religion, only Gabonese Christian females (AOR=1.53, p=0.020) and males (AOR=1.46, p=0.007) were more likely to know a place to get HIV test. Currently married female youth in Cameroon (AOR=1.64, p=0.001) and currently married (AOR=1.91, p<0.001) and formerly married female youth (AOR=5.01, p=0.002) in Gabon were more likely to know a place to get HIV test compared to never married youth. The AOR of knowing a place to get HIV test among Cameroonian youth showed a congruent increment with the wealth category status from the poorer to the richest, however, only the poorer female youth showed significant association compared to the poorest in Gabon. Cameroonian working males (AOR=1.93, p<0.001) and Gabonese working females (AOR=1.66, p<0.001) were more likely to know a place to get HIV test than those who do not work. Cameroonian both gender groups and Gabonese female youth with comprehensive HIV/AIDS knowledge and acceptance attitude were more likely to know a place to get HIV test compare to youth without comprehensive HIV/AIDS knowledge and acceptance attitude, respectively.

Table 4: Multivariate analysis showing associates of knowledge of a place to get HIV test among youth.

Lifelong HIV test experiences among youth

The multivariate analysis of the lifelong HIV test experiences among youth is presented in Table 5. The 20-24 years old youth were more likely to be tested in their lifetime than their 15-19 years old counterparts. The AOR of lifetime HIV testing among youth was found to be increased with the increase of educational status. There was no significant difference among the urbanrural residents and the different religions of the respondents towards lifetime HIV testing. Currently married and formerly married youth were more likely to be tested in their lifetime (except the Gabonese formerly married males) than never in union youth. Lifelong HIV testing has shown a significant positive association with wealth index among Cameroonian youth and the poorer group of Gabonese youth compared to the poorest. Working youth were more likely to be tested for HIV in their lifetime (except Cameroonian males) compared to not working youth. Among Cameroonian youth, comprehensive HIV/AIDS knowledge was significantly associated with lifelong HIV testing. Only Cameroonian males with acceptance attitude were more likely to be tested in their lifetime compared to youth with no acceptance attitude.

Table 5: Multivariate analysis showing associates of lifelong HIV test among youth.

HIV testing in the last 12 months

The multivariate analysis of HIV testing in the last 12 months among youth is presented in Table 6. In both countries and both genders, the 20-24 age groups were more likely to be tested for HIV in the last 12 months than the 15-19 aged youth. Education was significantly associated with HIV testing in the last 12 months in Cameroon except for males with primary education (AOR=4.82, p=0.124). However, in Gabon, only males with secondary education (AOR=6.15, p=0.018) showed a significant difference compared to the youth with no education. Cameroonian Moslem males were less likely to be tested for HIV (AOR=0.47, p=0.033) compared to youth with no religion. Currently married and formerly married youth were more likely to be tested for HIV compared to never in union youth. Wealth index of the respondents was significantly associated with HIV testing. Cameroonian female and Gabonese male working youth were more likely to be tested for HIV compare to not working. Cameroonian males and Gabonese females with comprehensive knowledge were more likely to be tested for HIV than youth without comprehensive knowledge. Place of residence and acceptance attitude were not significantly associated with HIV testing in the last 12 months.

Table 6: Multivariate analysis showing associates of HIV test in the last 12 months among youth.

HIV testing and receiving results in the last 12 months

The multivariate analysis of HIV testing and receiving results in the last 12 months is presented in Table 7. The 20-24 age group of both countries and both genders were more likely to be tested and received results of HIV tests compared to the 15-19 age group. In Cameroon primary (AOR=3.36, p<0.001), secondary (AOR=5.84, p<0.001), and higher (AOR=9.97, p<0.001) educated females and secondary (AOR=10.29, p=0.023) and higher (AOR=22.57, p=0.003) educated males, as well as in Gabon secondary (5.23, p=0.032) educated males were more likely to be tested and received results of HIV test than youth with no education. Currently and formerly married youth were more likely to be tested and received results than never in union youth except for formerly married Cameroonian males and currently and formerly married Gabonese males. The AOR of HIV testing and receiving results was increased with the rise of wealth index among Cameroonian females from the poorer to the richest and among Cameroonian and Gabonese males from the middle to the richest compared to the poorest. Cameroonian working females and Gabonese working males, as well as Cameroonian males and Gabonese females with comprehensive knowledge, were more likely to be tested and received results of HIV test compared to not working and without comprehensive knowledge youth, respectively. Place of residence and acceptance attitude of respondents was not significantly associated with HIV test and receiving results.

Table 7: Multivariate analysis showing associates of HIV test and receive results in the last 12 months among youth.

Discussion

History of HIV test experiences among youth

HIV test is an acute measure for HIV prevention programs and services [1], nevertheless, the HIV test experience among youth of both countries in this study was very low even considerable part of the youth didn’t know where to get HIV testing. Other studies from Cameroon, Gabon, and other countries had reported similar low results [1,7,13-16]. Though similar data was not available in the DHS data files of Gabon, the main reasons for HIV test uptake among Cameroonian youth were found to be asked for the test, offered and accepted, and required which indicates their low awareness, as they did not do it voluntarily. However, a welcoming achievement was found in receiving results of HIV testing which is higher than in many African countries [3]. The causes for the decreased awareness and HIV test uptake among youth can be many, for example, their own lack of knowledge and information about HIV/AIDS [38], limitations of the countries to provide the services due to some shortages like human, financial, material and technical resources and others like inadequate involvement of community volunteers or spiritual heads [16,17]. Other studies also indicated that knowing a place where to get HIV testing as one of the determining factors among HIV-positive and negative people whether to be tested for HIV [13,32,39]. Therefore, the governments, political and religious leaders, United Nations Agencies, national and international organizations, different stakeholders, private sectors, civil societies as volunteers and significant figures from community need to be effectively involved and integrate their efforts and play their model role to scale up HIV test among youth to curb HIV transmission. Besides, both expanding the coverage and accessibility of HIV test services and integrating the regular screening for HIV with the health care system may encourage youth thereby to facilitate HIV testing [4,39].

Comparison by country and gender

Gabonese youth were more likely to get tested for HIV in their lifetime, in the last 12 months and to be tested and received HIV test results than Cameroonian youth. The difference of HIV testing in the two countries may depend on their economy, in Gabon around 92% of the investment to fight against HIV was covered by the government and other Gabonese private sectors and only 8% was funded from international organizations [16]. Hence the involvement of the civil societies may increase the HIV testing among the people. However, in Cameroon dominantly was covered by the donation of international funds [17]. Moreover, the lack of human, financial and technical resources [17] may limit the provision of broad HIV testing in Cameroon. Males were less likely to know a place to get HIV test, to ever been tested for HIV and in the last 12 months, and to be tested and received results than female youth in both countries. The result of this study coincides with findings of other many studies [2,3,13-15,31,40,41]. Studies found that the reason for HIV testing uptake among females was accepting testing when it is offered, while among males it was voluntary testing [31] and significantly determined by the individual's economic status, behavior and knowledge of HIV/AIDS [42]. Therefore, the differences between male and female HIV test experiences may be directly explained by the increased rate of utilization of HIV test among females as part of the antenatal care [2,14,29,40].

Predicting factors of HIV testing among youth

The 20-24 age group youth were more likely to know a place to get HIV test, tested in their lifetime and in the last 12 months, and to be tested and received results compared to their 15-19 aged youth counterparts. Other studies from Tanzania and South Africa and Caribbean countries also reported similar findings [29,30,41]. It might be suggested that, with advancing in age, they may become more educated to increase their awareness and economically stable to be tested for HIV. Being urban resident was significantly associated to know a place to get HIV test but it was not significantly associated with testing in their lifetime, in the last 12 months, and testing and receiving results of HIV test in both countries compare to the rural residents. However, studies have been indicated that HIV test rates are higher in urban residents [3,13,14,30,41]. In this study, above 93% of the respondents had primary or above educational level and hence the urban-rural differences may be narrowed by their increased awareness due to education. An increased AOR of knowing a place to get HIV test, testing in their lifetime, testing in the last 12 months, and testing and receiving results of HIV test was showed a significant association with increased educational status compared to youth with no education. Similar results have been reported from Kenya, South Africa, Uganda, Zimbabwe, Tanzania and other sub-Saharan African countries [1,13,14,29,31,32]. Gabonese Christian youth were more likely to know a place where to get HIV testing compared to youth with no religion. Other studies also found a strongly significant association of religion with HIV testing [3,39]. There have been some reports that indicate involvements of religious groups in the implementation of HIV prevention programs by donating money or participating in the program as sanitary providers of the HIV test providing centers [17], which may help them to have awareness about HIV testing. Nevertheless, Cameroonian Moslem males were less likely to be tested and to be tested and received results than youth with no religion. Generally, currently married and formerly married youth were more likely to know a place to get HIV test, to be tested in their lifetime and in the last 12 months, and to be tested and received results than the never in union youth. Similar findings were reported from other sub- Saharan African countries and Caribbean countries [7,39-43]. This is an alarming finding which clearly reveals that youth are not only restricted to the access of the HIV prevention services by their own lack of knowledge [38], but most of the reproductive health services in developing countries are also intended to serve the needs of married people only [23]. Other researchers had also supported that, in particular, the needs of adolescents and young people are often ignored in many countries during the development of national HIV prevention programs, sexual and reproductive health policies and budget allocations [16,23]. As a result, young people living with HIV/AIDS often have inadequate access to health and social support services and face considerable stigma and discrimination [44]. Wealth index of both genders in both countries showed an increment in AOR with knowing a place to get HIV test, testing in their lifetime, testing as well as testing and receiving results of HIV test compared to the poorest. The finding is congruent with the results of other studies from Uganda, Tanzania, Ivory Coast and other countries of sub-Saharan Africa [2,14,29,32,40]. Other studies found that voluntary HIV testing was significantly determined by the individuals economic status [31,42]. Working youth were more likely to know a place to get HIV test, to be tested in their lifetime, tested in the last 12 months, and to be tested and received results of HIV test than not working youth. Other studies from Kenya and South Africa also found similar results [1,13]. The reason may be related to their economic differences that the working youth are more economically stable than the not working to get tested for HIV and they may get information related HIV in their work places. Youth with comprehensive HIV/AIDS knowledge were more likely to know a place to get HIV test, to be tested in their lifetime and in the last 12 months, and to be tested and received results of HIV test compared to youth without comprehensive HIV/AIDS knowledge. Having a correct knowledge of HIV/AIDS has been found to be significantly associated with HIV testing [2,13,14,32]. Media exposure, participation in HIV/AIDS campaigns and discussion of parents to their teenagers about HIV were mentioned as determiners of HIV/AIDS knowledge and thereby boost HIV testing among youth [1,30,31]. The youth of both countries and both gender groups who have acceptance attitude towards people living with HIV were more likely to know a place to get HIV test. But only Cameroonian males having acceptance attitude were more likely to be tested in their lifetime. It is believed that, stigma in its different types; social rejection stigma, disclosure concerns stigma, or observed enacted stigma as a barrier to HIV testing [31,45].

Conclusion

HIV testing is continued to be the key strategy for HIV prevention. However, lifetime and in the last 12 months HIV test experiences among Cameroonian and Gabonese youth are very low and even significant proportion of the youth do not know where to get HIV test. Hence, both countries need to implement strategies targeting those younger, unmarried, not educated, not working, and economically disadvantaged youth to increase their knowledge and attitude thereby to boost their motivation and awareness towards HIV testing. Making HIV testing centers more accessible and visible and integrating HIV screening with the health care system may expand the access among youth to facilitate the diagnosis, treatment, care and support. Besides, community and religious leader’s involvement and making public health messages targeting these youth at higher risk can be imperative to encourage HIV test uptake among youth.

Limitations of the study

This study consists of some limitations related to the crosssectional nature of the study; it looks at associations, not causes and effects. The DHS is a household-based survey, and hence excludes significant non-household population groups, like those living on the street or in institutions, for example, prisons, colleges or boarding schools, military barracks, or refugee camps, which could have different HIV test experiences than the household population. Similarly, as the questionnaire is designed to collect self-reported responses, there could be recall biases and socially desirable responses. Besides, the missing data in the data files of the countries may affect the results.

Competing interests

The authors declare that they have no competing interests.

Acknowledgements

We would like to thank the Demography Health Surveys (DHS) Program, ICF International Rockville USA, for allowing us to use the raw data of this study.

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