Horizons Report | December 2006 | Promoting VCT at the Workplace

horizons_report.gif (8665 bytes)

December 2006

Promoting VCT at the Workplace
Studies in Kenya and Zambia show increased acceptability and uptake of VCT by health workers and teachers

Group of health workers looking at literature on HIV.

Health workers in Zambia receive information about HIV testing during a World AIDS Day event.

Photo credit: Arthur Kalimbwe/Zambia Medical Association

For those individuals who are not seeking routine or curative health services, voluntary counseling and testing (VCT) remains an essential mechanism for learning one’s HIV status. One way to encourage VCT uptake among the general population is to provide VCT services or referrals through workplace HIV programs.

However, two large and influential groups of workers—health providers and teachers—are often overlooked by workplace programs. One reason is that HIV program planners wrongly assume that these groups are knowledgeable about HIV-related issues, and that they do not need targeted interventions to address HIV in their personal and professional lives. But research conducted by Horizons and partners in Zambia and Kenya shows that health providers and teachers have unmet HIV prevention and care needs, and that they can benefit from workplace programs that include education about and promotion of VCT.

Low Levels of Testing among Hospital Workers

In Zambia, Horizons, in collaboration with the University of Zambia/INESOR, the Zambia Medical Association, the Zambia Health Education and Communication Trust, and the Zambia Integrated Health Project, is conducted an intervention study to assess a workplace HIV program for hospital employees. Researchers began in 2004 by collecting data from 1,424 hospital workers from five large hospitals in two Zambian provinces. The baseline quantitative data were supplemented by qualitative data from focus group discussions (FGDs) with 200 additional staff. Both samples included physicians and other health care workers, as well as administrative staff.

To assess awareness about on-site HIV testing facilities, participants were asked if they knew exactly where in the hospital they could get an HIV test done. Nearly all survey respondents (88 percent) knew where to go. However, when asked whether they had been tested for HIV, just over a fourth of respondents said they had. Medical doctors were the most likely to have tested (55 percent), compared to nurses (33 percent) and clinical officers (12 percent). FGD results suggested the main reason for not testing was fear: many hospital workers feared the results, were unsure about the process, and feared colleagues’ reactions:

I am afraid but I want to do it. . . . I will do it. But I am afraid because of my fear of having misleading results. I really want to know the procedure . . . how they do it, how the test is being carried out, so when I am sure about those things then I can go ahead. Though I fear the outcome.
—Female nurse

I am a coward. I have an intention of going for a test but I am still a coward. But one day, I will.
—Female nurse

FGDs indicated that some providers get tested frequently. Survey results showed that the number of times respondents had been tested ranged from 1 to 10 times (average 2.1 times), with men reporting getting tested slightly more often than women. Doctors had tested the most times, while nurses had tested the fewest times. Thus, medical doctors were not only more likely to have been tested in the first place, but also to have been tested multiple times.

Respondents who had a sexual partner were also asked whether this individual had been tested. About 21 percent reported that their partner had been tested, including 19 percent of men and 22 percent of women. This implies that the remainder—79 percent of respondents with a sexual partner—did not know that person’s status. Again, medical doctors (44 percent) were by far the most likely to report that their sexual partner had been tested.

Analysis of HIV testing by sexual partnerships revealed that those with multiple sexual partners in the last year were no more likely to have been tested than those with a single sexual partner. Twenty-seven percent of males and 28 percent of females with multiple partners had been tested for HIV, proportions nearly identical to those who had just one partner (27 percent for monogamous males and 26 percent for monogamous females). Thus, despite their higher risk-taking behaviors, hospital workers with multiple partners were not more likely to know their HIV status.

When asked why they had not been tested for HIV, about 40 percent of those who were monogamous that year and 36 percent of those with multiple partners said “no particular reason/don’t know why.” The second most common explanation was “not feeling at risk,” which was mentioned by 31 percent of those who were monogamous respondents and 19 percent of those with multiple partners. The third most common reason was “afraid of the results,” cited by 13 percent of monogamous respondents and 26 percent of those with multiple partners. When asked whether they would like to be tested, 43 percent of monogamous respondents and 46 percent who had multiple partners said they would like to be tested. This suggests that more than half of untested hospital employees who reported risky sexual behavior did not want to know their HIV status.

Increase in Serostatus Awareness

Baseline findings pointed to the need for a workplace program in the hospitals that encourages HIV risk-reduction and serostatus awareness, among other aims. An intervention was initiated in August 2004 that targeted all hospital staff in two of the five study hospitals (the other three hospitals served as delayed comparison sites). Developed with hospital management, the intervention consisted of peer education activities implemented weekly by trained health workers, the distribution of behavior change communication materials, and the establishment of condom access points. Health workers were given information on where they could go for HIV testing in the area, including in their facility.

Many hospital workers feared their HIV test results, were unsure about the process, and feared colleagues’ reactions.

Prior to the onset of peer education activities, sensitization workshops open to all health workers in the two intervention hospitals were held over several days. These touched on key topics that would be further addressed by the peer educators, including understanding HIV and AIDS, VCT, positive living, stigma, and more. Just over half of the 1,327 hospital staff attended.

A total of 79 health workers were trained as peer educators in the two intervention hospitals. The peer educators represented a variety of occupations, including doctors, nurses, paramedics, administrators, as well as custodial and support staff. Training was held in August 2004 over a 7-day period.

A follow-up survey was conducted 18 months after the start of the intervention to measure its impact. Preliminary results showed a 68 percent increase in the proportion of hospital workers in the intervention sites who reported having been tested for HIV, compared to a 35 percent increase in the comparison sites. Findings from FGDs and in-depth interviews conducted at the end of the intervention period suggest positive changes among the hospital workers:

. . . before the program came, health workers were scared to go for VCT and treatment, but now at least they are willingly going there because of the sensitization. . . . So as of now . . . I am proud to say the situation has greatly improved because of the steps that have been taken . . . people go for VCT.
—Female hospital manager

Hospital managers were supportive of the intervention; they participated in activities, encouraged staff to participate as well, and provided t-shirts and refreshments.

In addition, the intervention has led to other important developments. For example, prior to the intervention in one of the study hospitals, there was no room available where health workers could be counseled and tested privately; instead they would meet under a tree or look for an empty room in the hospital and often be interrupted. Recognizing the need for a dedicated VCT room for staff, the executive director of the hospital commissioned the construction of a separate site.

A final report on the study’s findings will be available in early 2007.

Teachers Fear HIV Testing

In Kenya, where teachers represent the country’s single largest workforce, it is increasingly recognized that teachers are at risk of HIV infection even as they are relied upon to deliver prevention messages to children and youth. As a result, there has been a move to target teachers as the direct beneficiaries of school-based HIV interventions. In partnership with UNICEF, Horizons conducted operations research to test one such workplace model of HIV prevention and care and to assess changes in teachers’ knowledge of HIV, risk behaviors, and utilization of VCT.

A total of 120 randomly selected public schools (80 primary and 40 secondary) in four Kenyan districts participated in the study, which began in 2004. At baseline, all teachers in the study schools were invited to complete a self-administered, structured questionnaire; 1,255 teachers completed the questionnaire (about 70 percent of eligible respondents). A total of 24 FGDs were held with teachers to supplement information from the quantitative survey.

Baseline data showed that although nearly all (90 percent) of the teachers knew where to get tested for HIV, only 25 percent of the sample had been tested. Among those not tested, only a third desired to be tested, while the remainder did not wish to be tested or had not made up their minds.

All respondents, regardless of their testing status, were asked whether they were afraid of the HIV test. Over half said they were “very afraid,” and FGDs revealed fears both of the results and of reactions from peers.

. . . some people say that these people who are tested and are positive, they die quickly because of stress.
—Male teacher

For me I can’t even have the guts to go for counseling or testing here because teachers are the centers of discussion . . . just the fact that they’ve seen we are going for the test is bad enough, it means I have it [AIDS].
—Female teacher

Teachers’ responses suggested that some might be more responsive to testing if their fears were addressed and their questions answered.

I would suggest that the ones organizing this [research] help people who are afraid of testing HIV-positive like me. That is, come up with a way to help them accept their results without much panic, which can even cause immediate death.
—Female teacher

I do not know how many times I should go for a test. Is it every time before or after sex with my wife?
—Male teacher

I would like to take a test with my husband but he may refuse. What will I do?
—Female teacher

Teachers’ knowledge of the HIV status of their sexual partners was low. Of those with a sexual partner, only 24 percent said their partner had been tested; the remaining 76 percent said their partner had either not been tested or they were not sure. Thus over three-quarters of teachers were sexually active with a partner whose HIV status they did not know.

Demystifying the HIV Test

In collaboration with the Ministry of Education, Teachers Service Commission’s AIDS Control Unit, Kenya Institute of Education (KIE), and UNICEF, Horizons implemented a one-year HIV and AIDS workplace initiative for teachers from schools in two of the four study districts. Known as Teachers Matter, the initiative uses a peer education model to increase HIV testing, encourage safer sex practices, reduce stigmatizing attitudes toward HIV-infected people, and share information about teachers’ rights with regard to HIV and AIDS.

Over three-quarters of teachers were sexually active with a partner whose HIV status they did not know.

As part of a week-long training to equip teachers to be peer educators, emphasis was placed on reducing fears of testing. The process was demonstrated by VCT counselors and HIV testing kits were passed around for the teachers to see. In addition, VCT was offered via a mobile unit and about a third of the 111 peer educator trainees tested for HIV for the first time.

During the ongoing peer education program, teachers meet once a week with the peer educators for about 45–60 minutes. Relevant HIV and AIDS education materials are provided to the teachers and appropriate referrals are offered. The unit on VCT includes information on the testing process, the outcomes, pre- and post-test counseling, couples testing, and stigma and discrimination. The program is currently reaching about 2,000 teachers.

Feedback from the participating schools indicates that the program has fostered openness to discuss issues, such as sexuality, condom use, and HIV testing, that would otherwise have been considered taboo. There are also preliminary reports of reduction in stigma toward teachers living with HIV. Follow-up data collection to determine program impact will occur in February 2007 and a final report will be available mid-year. If proven successful, the researchers will recommend that this workplace initiative be rolled out in all schools, so that the nearly quarter of a million teachers in the country can benefit from it.

The study has already spurred the Ministry of Education to create its own VCT site at their main headquarters in Nairobi, which is open to all staff, with the idea that before they can promote VCT to others they need to begin with themselves. The services have elicited a huge response from over 20 other government agencies and parastatals who have requested similar services.

For more information about this study, contact Karusa Kiragu (kkiragu@pcnairobi.org).

Return to Table of Contents | Page 2 >

See Also

For additional information please contact:
Horizons
Population Council
4301 Connecticut Ave. NW, Suite 280
Washington, DC 20008
Telephone: +1 202 237 9400
Facsimile: +1 202 237 8410
E-mail: horizons@popcouncil.org

Print this page

@
E-mail this page

This page updated
11 January 2007