HIV Preventive Behaviors and Associated Among Gold Mining Workers in Dima District, Southwest Ethiopia, 2019: Community Based Cross-Sectional Study

Background: The prevalence of HIV/AIDS is increasing over time, leading to a signicant number of life losses. According to the USAID 2018 report, 36.9 million (35.1 million adults) people globally were living with HIV, 1.8 million people became newly infected with HIV, and 940 000 people died from AIDS-related illnesses in 2017. Mining workers are at high risk of acquiring HIV and infecting others, while successful preventive m easures are a key solution. Objective: To assess HIV preventive behaviors among gold mining workers in Dima district, southwest 2019 Methods and materials: A community-based cross-sectional study was conducted from March 1 st to 31 st , 2019. The data were collected through face-to-face interviews. The collected data were coded and entered into Epidata version 4.2.0.101, cleaned, and analyzed using SPSS version 21 statistical software. A binary logistic regression was conducted to determine the association using odds ratios at 95% condence intervals. A P-value of less than 0.05 considered as the level of signicance for HIV preventive behaviors. Results: Of 279 (61.3%) of the respondents have good practices of HIV prevention. Factors associated with good preventive practice were not alcohol drinkers (AOR= 2.86, 95%CI:1.30-6.29), not chew Khat (AOR= 2.09, 95%CI: 1.09-4.02), having good knowledge about HIV (AOR=1.81, CI:1.16-2.83), favorable attitude towards HIV prevention (AOR=4.76, 95%CI:3.02-7.49), and high perceived susceptibility to HIV were (AOR=2.63, 95%CI:1.63-4.24). Conclusion: Only about 61% of the mining workers in the study area were practiced HIV preventive behaviors. Not alcohol drinkers, having good knowledge about HIV, having a favorable attitude toward HIV prevention, and having high perceived susceptibility to HIV were factors associated with the practice of HIV preventive behaviors. Efforts have to be made by local governments and other concerned bodies to increase preventive behavior.


Background
The prevalence of HIV/AIDS is increasing over time, leading to a signi cant number of life losses (1,2).
HIV epidemics continue to represent a public health threat worldwide, leading to causing deaths in sub-Saharan Africa (3). According to the USAID 2018 report, 36.9 million (35.1 million adults) people globally were living with HIV, 1.8 million people became newly infected with HIV, 940 000 people died from AIDSrelated illnesses in 2017. Most at-risk populations (MARPs) and their sexual partners account for 47% of new HIV infections globally and 16% of new HIV infections in eastern and southern Africa. The risk of acquiring HIV is 13 times higher among female sex workers (1).
The adult HIV prevalence in Ethiopia in 2016 was estimated to be 1.1%. There is substantial prevalence variation by region (6.6% in Gambella, 5.0% in Addis Ababa, and 0.7% in Southern Nations, Nationalities and Peoples' (SNNPR) region) of Ethiopia (2). According to Ethiopia Public Heath Inistitute 2017 report, the prevalence of HIV shows a signi cant increment in adults of both sexes, but the incidence shows slow decrement. The annual AIDS-related deaths become decline from time to time (4).
Considering the fatal increment of HIV prevalence, there is a great struggle globally to end its epidemic. In 2014 UNAIDS launched new targets named 90-90-90 to help end the AIDS epidemic. According to this new target, by 2020, 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained ART and 90% of all people receiving ART will have viral suppression. In 2017 the global achievement of these three 90 s was 75%, 79%, and 81% respectively which shows the need for extra effects for the full achievements (1,5). HIV testing is among the effective preventive activities. It can be the provider-initiated, voluntary based or self-test approach. It is being implemented in a major segment of the population by paying due attention to key populations like sex and mining workers (6)(7)(8). The numbers of HIV testing among people in Sub Saharan Africa have increased by 66% in the past decade and about one-third are diagnosed late, results in an increase in the risk of HIV related morbidity and also can result in onwards transmission of HIV in the community (9).
Mining workers are among a population classi ed as Most-At-Risk Populations (MARPS). This is to indicate that the risk occurrence of HIV infection among this population is high. To control the HIV in general population controlling the disease in this population is a key issue (8,(10)(11)(12)(13). For the successful control, evidence on prevalence rate, the practice of prevention methods and experience of key populations are important.
The factors that contribute for the high prevalence of HIV/ AIDS are diverse and might include education, income, female labor force participation, place of residence, demographic and cultural factors, male circumcision, condom use, access to counseling and testing, knowledge and awareness of HIV/AIDS virus and access to antiretroviral therapy (14)(15)(16).
HIV prevention is a complex issue with no magic bullet for its success (17). However, having good knowledge, attitudes and practices (KAP) of HIV prevention are essential in order not to acquire HIV infection and to prevent the disease from spreading (9). Adults, mining workers are the highest risk populations in acquiring HIV/AIDS when compared to others (8). An improved knowledge, change attitude and change behavior are considered as the main factors that increase HIV test uptake (18). So, this study was aimed to assess HIV preventive behaviors among mining workers in Dima woreda, southwest Ethiopia, 2019.

Methods And Materials
Study area and period The study was conducted in Dima district, Gambella region southwest Ethiopia from March 1st to 31st, 2019. Dima woreda is one of the woredas in Agnuak Zone, Gambela Region of Ethiopia. The Dima district is among HIV high prevalent areas in Ethiopia. There are several miners and commercial sex workers in the area. There about ten mining center in the district.

Study design
A community-based cross-sectional study was conducted among mining workers in Dima woreda.

Population
The source population were all mining workers in Dima district while the study population were randomly selected mining workers in Dima woreda.

Eligibility criteria
Adults with age ≥ 18 were included in this study. Adults who ful ll the inclusion criteria but who are severely ill or unable to verbally communicate during the data collection time were excluded from the study.

Sample size determination and sampling technique
The sample size was determined by using single population proportion formula considering the following assumptions p = 50 percent (the proportion of good preventive behaviors); d = 0.05 margin of error and 95% con dence level with a value of Z = 1.96. n= (Z α/2) 2 P (1-P)/d 2 = 384. Using a non-response rate of 20% which give a nal sample size of 461.
Regarding the sampling procedure, there are 10 rural kebeles in Dima district where mining workers mostly found. We have randomly selected 50% from these kebeles and the sample size was equally allocated for each of them and a convenience sampling technique was used to get mining workers for interview.

Data collection tools and procedures
A structured questionnaire was developed from different works of literature (19)(20)(21)(22). The questionnaire has parts like socio-demographic, behavioural pro le, knowledge of HIV, Practices of HIV prevtive beahaviours and perceptions of HIV. Questionnaires were translated to Amharic from the English version. Then, back to English by an independent person to assure its accuracy. The questionnaire was pre-tested on 5% of the total sample size, which is a similar population to the study area Bero district. Bero the nearer district with numbers mining sites. The collected data were evaluated for completeness, clarity, and consistency by the supervisor and principal investigator on a daily basis. Ten data collectors and three supervisors who were quali ed with bacheol of science (BSc) in Nursing were recruited and trained for two days before a data collection on data collection tool, approach to the interviewees, details of interviewing techniques, respect and maintaining privacy, and con dentiality of the respondents.

Data quality management
The English version questionnaire was rst to be translated to the Amharic language. Then, it translated back into English to check for its consistencies. Two days of training were given for the data collectors and supervisors concerning the objectives and data collection procedures. Finally, pre-testing was conducted on 5% of the sample outside the district. Close supervision was made daily to ensure the completeness and consistency of the lled questionnaires. Epidata manager version 4.0.2.101 was used for data entry to minimize errors during data entry.

Data processing and analysis
The collected data were coded and entered using Epidata manager version 4.0.2.101, cleaned and analyzed using SPSS version 21 statistical software. Summary statistics for different variables were presented using frequency tables and graphs. A binary logistic regression was computed to determine the association using crude and adjusted odds ratios at 95% con dence intervals. Independent variables with p-values less than 25% were a candidate for multivariable logistic regression. A p-value of less than 0.05 will be considered as the level of signi cance for HIV preventive behaviours in multivariable logistic regression.

Measurement and operational de nitions
Knowledge It was measured by 17 yes or no questions. Then the mean score were computed and participants who scored greater mean score of knowledge questions were categorized as knowledgeable and not knowledgeable otherwise.

Attitude
Assessed by 20 likert question ranging from 1 to 5 (strongly disagree to strongly agree). The negative questions were reverse coded and mean score was computed. Participants who scored greater than mean score of attitude questions were categorized as have a positive attitude and have a negative attitude otherwise.

Perceived severity
Assessed by 6 likert question ranging from 1 to 5 (strongly disagree to strongly agree). The negative questions were reverse coded and mean score was computed. Participants who scored greater than mean score of were categorized as having a high perceived severity otherwise low.

Perceived susceptibility
Assessed by 6 likert question ranging from 1 to 5 (strongly disagree to strongly agree). The negative questions were reverse coded and mean score was computed. Participants who scored greater than mean score of attitude questions were categorized as having a high perceived susceptibility otherwise low.
HIV preventive behavior-if an individual is abstaining from sexual intercourse in the last six months until the time of study period or, having only one sexual partner and tested for HIV before their rst sexual relationship, tested for HIV infection in last three month of the study period and consistently use a condom it was said to be in HIV preventive behavior (23).

Socio-demographic characteristics of mining workers
A total of 455 respondents participated in giving a response rate of 98.6%. Majority of the respondents between the age group of 25-34 years 220 (48.4%). The mean age of the participant was 25.84 (5.34 SD). Three hundred (65.9%) of the respondents were single in marital status. Regarding their religion 274 (60.8%) follower followers of orthodox Christianity. Concerning ethnicity, 126 (27.7%) of the respondents were Amhara. One hundred fty (33%) of the respondents were completed in secondary school. Regarding the median monthly income of respondents was 1000 ETB, and 256 (56.3%) of them were earning less than 1000 ETB. Table 1.

Sources of information about HIV and its prevention
The study participants have access to different sources of information on HIV. The major source of information about HIV was radio. Figure 1.

Practices of HIV prevention among mining workers
From interviewed participants, 415 (91.2%) were sexually active. Two hundred seventy-nine (61.3%) of the respondents have practices of HIV prevention. Three hundred eighty-nine (94.6%) of the respondents were sexually active in the last 12 months. About 235 (57.3%) of the respondents had sexual intercourses with casual partners while 82(20%) of them had sexual intercourses with commercial sex workers. Two hundred twenty-one respondents (69.5%) had 2 and more sexual partners. Only 282 (81.3%) of them were using a condom consistently. Table 3. Reason for non-consistent condom use The participated mining works mentioned different reasons for non-consistent which may be risky for HIV transmissions. The most commonly listed reason for non-consistent condom use was forgetfulness after drinking alcohol followed by trusting sexual partners Fig. 2.

Reason for not undergoing HIV testing
The leading reason listed by mining workers for not undergoing regular HIV testing was service is not easily available. Figure 3.  According to this study mining workers, those do not drink alcohol were more likely to practice HIV preventive behaviors than those drinking alcohol. Similarly, a study conducted on the effects of hazardous and harmful alcohol use on HIV incidence and sexual behavior showed that unsafe sex, partner violence, and HIV incidence were higher in women with alcohol users (24). The study conducted among college students in Gambella town also showed that alcohol drinkers are less likely to practice preventive behaviors than non-alcohol drinkers (22). Similarly, a study conducted on Alcohol use and HIV risk behaviors among rural adolescents in Khanh Hoa Province Viet Nam showed that alcohol use was signi cantly associated with engagement in sexual behaviors (25). Also, a study conducted in Jigawa  (27). Similarly, a study conducted on HIV/AIDS preventive behavior among college students in Gambella town, Southwest Ethiopia using the health belief model indicated that participants with good knowledge were more likely to practice HIV preventive behaviors than those with poor knowledge (22).

Attitude towards HIV prevention
This might be because individuals with comprehensive knowledge protect themselves since they know how HIV can be transmitted and the effect of HIV on their life.
Also, mining workers, who have a favorable attitude about HIV prevention were more likely to practice HIV preventive behaviors than workers with an unfavorable attitude. This might be because of those individuals with favorable attitudes may have knowledge about the disease and can easily protect themselves from getting the disease.
In this study perceived susceptibility of the workers toward HIV determines their practice of HIV prevention. Participants who had high perceived susceptibility for HIV were more likely to practice preventive behaviors than respondents with low perceive. Similarly, a study conducted on the utilization of HIV/AIDS prevention methods among university students residing at a selected university campus showed that perceived susceptibility to HIV/AIDS showed a correlation with self-e cacy on condoms and their utilization (28). This is because when they know as they are susceptible, they can take preventive measures.
Limitation of the study Social desirability bias may affect this study since the participants might hide some practices. Also the nature of cross sectional study do not show causalities.

Conclusion And Recommendation
HIV preventive behavior is low in the study area. HIV preventive behaviors were associated with alcohol drinking, chat chewing, knowledge related to HIV, attitude towards HIV prevention and perceived susceptibility for HIV. Increasing behavior of HIV preventive behaviours through BCC is the key intervention.

Declarations Ethical consideration
Ethical approval was sought from the Research Ethics Committee (REC) of the College of Health Sciences of Mizan-Tepi University. And Supportive letter was obtained from the zones' health o ce. Written informed consent was obtained from the study participants after interviewers explained the objectives, purpose, risk, bene t, participants' right and con dentiality of the study.
The nancial fund was covered by Mizan Tepi University. The funding body (Mizan Tepi University) has no role in the design of the study, data collection, analysis of data, interpretation of result, and writing manuscript.

Authors' Contributions
Tadesse Nigussie drafted the manuscript. All authors were involved in the conception, design, acquisition of data, analysis, and interpretation of the results. Finally, all authors read and manuscript for publication.

Availability of data and materials
All data generated during and/or analyzed during the study are available from the corresponding author on reasonable request.

Consent for publication
Not applicable