1. Social barriers to uptake of HIV testing in Côte d’Ivoire Kévin JEAN, France LERT, Rosemary DRAY-SPIRA Inserm UMR-S 1018, Centre for Research in Epidemiology and Population Health, Villejuif, FRANCE ICASA 2011 – December 6th Kévin JEAN - ICASA 20111

2. Background HIV prevalence : 3.4% (UNAIDS, 2010) 80% of HIV+ are unaware of their HIV status Côte d’Ivoire Gate to treatment Prevention Why testing for HIV? Expanded/universal HIV testing The Seek, Test and Treat approach to reverse the HIV epidemics Kévin JEAN - ICASA 2011 2

3. But … Many obstacles to HIV testing : –Poor and unequal testing services provision –Social determinants Gender, educational level, familial/economic/professional situation (Cremin et al., 2009; Wringe et al, 2009; Peltzer et al., 2009) Sexual behaviors (Venkatesh et al, 2011) Knowledge/attitudes toward HIV/AIDS (Ostermann et al, 2011) Necessity to identify these determinants in the context of Côte d’Ivoire  Promoting HIV testing in order to treat better and more Kévin JEAN - ICASA 2011 3

4. Objective Identify who get voluntary tested in Côte d’Ivoire (except through prenatal test)  There are social barriers to access to HIV test Population –2005 DHS: nationally representative cross-sectional survey Socio-demographic / socio-economic information Sexual behavior Knowledge/attitude about HIV; HIV testing history –Exclusion criteria Having never heard of HIV/AIDS Having never had a sexual intercourse  3438 men and 3677 women aged 15-49 Kévin JEAN - ICASA 2011 4

5. Statistical analysis Kévin JEAN - ICASA 2011 Outcome –Recent uptake of voluntary HIV testing (<2 years) Covariates –Demographic factors: age, region of residence –Socioeconomic factors : educational level, wealth index quintile, family/employment status –Sexual behaviors : lifetime number of sexual partners, age at 1 st intercourse, use of condom at last intercourse –Knowledge & attitudes toward HIV/PLWHA: 6-scaled knowledge score, 6-scaled stigma score Gender-specific multivariate logistic regression –Including all significant variables from univariate analysis 5

6. Descriptive of the population Men (N=3438)Women (N=3677) Response rate (%)83.685.9 Median age2927 Living in Abidjan27.324.4 No educationnal attainment32.451.5 Working 74.665.1 Familial situation: Single Living in union Separated/widowed 43.4 49.7 6.9 27.0 63.1 9.9 Recent uptake of voluntary HIV testing 6.15.3 Kévin JEAN - ICASA 2011 6

7. MEN (N=3438)WOMEN (N=3677) uOR [95%IC] aOR* [95%IC] uOR [95%IC] aOR* [95%IC] Region (ref=other regions) Abidjan 1.68 [0.90-3.12] 0.71 [0.28-1.78] 4.54 [2.28-9.01] 2.65 [1.30-5.38] Wealth index Switch to upper quintile 1.40 [1.16-1.68] 1.33 [0.97-1.80] 1.89 [1.61-2.22] 1.21 [1.01-1.46] Educ. level (ref=none) Secondary or more 2.26 [1.49-3.43] 1.22 [0.69-2.15] 5.67 [3.34-9.60] 1.96[1.09-3.51] Employment status (ref=working) Not working 2.13 [1.38-3.30] 2.00 [1.08-3.70] 1.18 [0.50-2.79] - Familiy sit. (ref=in union) Single 1.29 [0.67-2.50] 1.16 [0.68-2.00] 0.91 [0.48-1.73] - Separated/widowed 3.40 [1.72-6.71] 2.97 [1.15-7.71] 1.01[0.44-2.32] - Results: sociodemographic factors Kévin JEAN - ICASA 2011 7 * adjusted on age, region, wealth index, educ. level, employment status, family situation, nb of lifetime sexual partners, reported use of condom at last intercourse, HIV-related knowledge score, HIV stigma score

8. MEN (N=3438)WOMEN (N=3677) uOR [95%IC] aOR* [95%IC] uOR [95%IC] aOR* [95%IC] Nb of lifetime sex partners (ref=M:1-3/W:1) M:4-10 / W:2 0.96 [0.57-1.62] - 4.98 [2.41-10.3] 3.45 [1.58-7.53] M:>10 / W: >2 1.24 [0.54-2.85] - 6.72 [3.28-13.8] 3.25 [1.44-7.31] Use of condom at last intercourse (ref=no) Yes 1.52 [0.83-2.80] 1.16 [0.68-2.00] 2.12 [1.08-4.18] 1.23 [0.57-2.67] HIV-related knowledge (ref=low) High 3.04 [1.78-5.17] 1.86 [1.09-3.15] 9.27 [2.96-29.0] 4.37 [1.20-15.85] HIV stigma (ref=low) High 0.58 [0.37-0.93] 0.96 [0.60-1.53] 0.36 [0.17-0.94] 0.77 [0.36-1.63] Results: behavioral factors Kévin JEAN - ICASA 2011 8 * adjusted on age, region, wealth index, educ. level, employment status, family situation, nb of lifetime sexual partners, reported use of condom at last intercourse, HIV-related knowledge score, HIV stigma score

9. Discussion Low voluntary testing rate Offer-related factors –Regional heterogeneity (women) –Lower uptake of testing among working men  Difficult to leave work? (Ostermann et al, 2011) Knowledge and behaviors related factors – Influence of sexual behavior (women), HIV-related knowledge (men+women)  Relevant for information campaign –Lower uptake for women with an unique lifetime sexual partner  Eventually exposed through their partner's sexual behavior Social factors –Among men and women: uptake of testing associated with economic situation / educational level (Cremin et al., 2009) Kévin JEAN - ICASA 2011 9

10. Strengths, limits and conclusion of the study Strengths –Large sample (N=7115) –Nationally representative study with broad spectrum of variables –First in Côte d’Ivoire Limits –Old dataset (2005)  limited progress in overall testing rate (UNAIDS: 7,3% of general population tested for 2009 alone) Conclusion –Development of the testing offer, taking into account diversity in region, knowledge, education… Kévin JEAN - ICASA 2011 10

11. Thank you for your attention Thanks to our collaborators: CEPED (Paris) ENSEA (Abidjan) PACCI (Abidjan) EHESP (Rennes) Kévin JEAN - ICASA 2011 11