1. Washington D.C., USA, 22-27 July 2012www.aids2012.org The critical role of social cohesion on uptake of HIV testing and ART in Zambia Swiss Tropical and Public Health Institute University of Zambia

2. Washington D.C., USA, 22-27 July 2012www.aids2012.org BACKGROUND >14% HIV prevalence among adults 15-49  Despite free access  Despite free access to HIV related services: only 35% of women and 20% of men have been tested and received their results; up to one third treated with ARVs dropped out of the programs.  Reasons? health system constraints, poverty, gender inequality, stigma, beliefs… dynamics of decision-making ?

3. Washington D.C., USA, 22-27 July 2012www.aids2012.org METHOD Cross sectional study (part of a larger mixed-method study) Ethnographic study Systematic review QUESTIONNAIRE SD, SES, FS, K&B, STG, Health risk behav., Social relationships SURVEY Random community sample Nested Facility-based sample

4. Washington D.C., USA, 22-27 July 2012www.aids2012.org STUDY POPULATION  Four sites urban : LUSAKA and MAZABUKA rural: MBEZA and CHIVUNA  Inclusion criteria being over the age of 18 living in the area for at least six months  Exclusion criteria having participated in the community-based survey

5. Washington D.C., USA, 22-27 July 2012www.aids2012.org STATISTICAL ANALYSIS  Scales Mokken Scale analysis for polytomous items, implemented in STATA modules msp and Loevh (Non-parametric IRT)  Estimated effects  Estimated effects : Logistic regression analysis 3 steps: univariable – focal models – multivariable Retention in model if P-value<0.02

6. Washington D.C., USA, 22-27 July 2012www.aids2012.org RESPONDENTS’ CHARACTERISTICS Random communityFacility-basedTotal All respondents17645512315(100) HIV tested1231 (69.7)551 (100) 1782 (77) HIV positive238 (13.5)551 (100) 789 (34.1) On ART164 (9.3)551 (100) 715 (30.9) Female1019 (57.8)338 (61.3) 1357 (58.6) 18 to 24.9 years321(18.2)39 (7.1) 360 (15.6) 25 to 34.9 years512 (29.1)136 (24.7) 648 (28) 35 to 44.9 years483 (27.4)213 (38.6) 696 (30.1) 45 to 54.9 years202 (11.5)92 (16.7) 294 (12.7) 55 and above238 (13.5)67 (12.2) 305 (13.2) No education102 (5.8)31 (5.6) 133 (5.7) Primary811 (45.9)275 (49.9) 1086 (46.9) Secondary671 (38.1)194 (35.2) 865 (37.4) Tertiary125 (7.1)20 (3.6) 145 (6.3) Married1064 (60.3)313 (56.8) 1377 (59.5) Single414 (23.5)62 (11.3) 476 (20.6) Divorce/widow234 (13.3)167 (30.3) 401 (17.3) Urban884 (50.1)248 (45.1) 1132 (48.9) Employed1400 (79.4)443 (80.4) 1843 (79.6)

7. Washington D.C., USA, 22-27 July 2012www.aids2012.org Top 10 reasons for not testing

8. Washington D.C., USA, 22-27 July 2012www.aids2012.org Top 10 reasons for not initiating ART

9. Washington D.C., USA, 22-27 July 2012www.aids2012.org Risk of not testing Explanatory variablesAOR95%CIP-value Urban2.45*1.873.210.000 Female0.65*0.500.800.001 Wealth (poor)1.14*1.011.280.035 Married0.44*0.340.570.000 Widow/divorced0.660.361.200.172 Social capital Do not attend religious services1.33*1.151.540.000 Do not participate in any community activity 1.31*1.011.700.039 Social cohesion Problems in neighbour relationships 1 1.24*1.111.370.000 * significant, p=0,005 1 combines "people in this neighbourhood don't get along with each other; People around here are willing to help their neighbours".

10. Washington D.C., USA, 22-27 July 2012www.aids2012.org Risk of not initiating ART * significant, p=0,005. 1 combines "in times of crisis I can turn to my spouse/partner for support; My spouse/partner and I get along well together; I trust my partner; Feel supported by people of my household". 2 combines "if someone in the household misuses money it is acceptable to beat him/her; In my household if a wife comes home late without the permission of the husband she will be beaten". 3 combines "traditional medicine better relieves symptoms compared to ARV’s; traditional medicine cures; is easier to apply; easier to access; HIV may be caused by witchcraft; ARV’s are against black people; African people used as guinea pigs". Explanatory variablesAOR95%CIP-value Widow/divorced0.500.171.460.207 Social cohesion Problems in neighbour relationships Problems in family relationships 1 1.35*1.031.770.030 Tolerance to domestic violence 2 1.36*1.011.780.039 Beliefs in efficacy of traditional medicine 3 2.43*1.693.490.000

11. Washington D.C., USA, 22-27 July 2012www.aids2012.org Conclusions Less cohesive communities put individuals at higher risk of non-accessing HIV services. For the initiation of ART, family cohesion and trust in traditional medicines play a bigger role. Not only enacted violence adds to the burden of HIV but its tolerance within families also jeopardizes access to treatment. LIMITATIONS - design does not allow establishing a temporal relationship; - self reported rates (recall bias).

12. Washington D.C., USA, 22-27 July 2012www.aids2012.org Recommendations  Interventions should target community and family in addition to individual and/or couple.  Promote community participation and collective action. (Acknowledge traditional relationship systems)  For future research longitudinal studies need to clarify the causal links between social cohesion and HIV testing and to confirm replicability in other contexts.

13. Washington D.C., USA, 22-27 July 2012www.aids2012.org Acknowledgments  We sincerely thank the contribution of: Respondents who shared their time with us Collaborators: Virginia Bond (Zambia AIDS Related Tuberculosis, Lusaka, Zambia)  We gratefully acknowledge the support of: Local authorities and the Ministry of Health, Zambia SNSF, AECID