The most significant findings were that knowledge and attitude significantly affect practices on voluntary HIV counselling and testing among adults attending outpatient clinics at Gulu Regional Referral Hospital. This was presented by a formula from the regression analysis as VCT practices = 0.478 VCT knowledge + 0.257 VCT attitude. This finding suggests that investing in knowledge and attitude can significantly influence practices on voluntary HIV counselling and testing among the study population. This finding has implications on how VCT practices could be improved in this community, for example, by increasing information on VCT, it would improve knowledge and attitudes of community members to undertake VCT services. The Ugandan Ministry of Health and administration of Gulu Regional Referral Hospital could take advantage of this finding to increase VCT uptake in this community by making IEC materials readily available and using radio talk shows for reaching out to community members explaining the importance of VCT services in access and care for HIV and AIDS patients. This could become very useful, as statistics show that the incidence and prevalence of HIV is slowly and steadily increasing in Northern Uganda, disrupting the gains already achieved by Uganda over the bane of HIV and AIDS.
The sociodemographic characteristics of participants were comparable to many studies conducted in Northern Uganda [5, 6, 7, 10], where most respondents were young adults in their productive age-group of 20-29 years, females in the ratio of 1.4:1 to males and the majority were students, not married and had attained ordinary level of education (Table 1). Other sociodemographic data, such as tribe, occupation, and religion, were consistent with the pattern of population distribution in Northern Uganda and did not significantly affect VCT practices in this study population [5, 6, 7, 10].
To our knowledge, most participants in the current study had adequate VCT knowledge on what, why, how, where and when VCT services were conducted (Table 2). Similarly, a study conducted among students at a polytechnic in southeastern Nigeria found 115 (63.2%) students were aware of VCT services, with 68 (59.1%) having heard about it a year prior to the study [14]. In addition, mass media and churches were the most common sources of VCT information [14]. However, most students did not know where VCT services could be obtained, and their knowledge on VCT was low [14]. Nevertheless, 127 (69.8%) students approved the need for counseling prior to testing, and 117 (64.3%) were ready to take a positive test result in good faith [14]. Similarly, the commonest source of VCT information for the current study was radios and schools, while parents were the least common (Table 3). Similarities observed in the two studies have implications on how the application of this information could become strategy to augment VCT knowledge, attitudes, and practices. These authors suggest that the line ministries in Uganda and Nigeria could use radios, schools, and churches as means for engaging, mobilizing, and sensitizing the population on voluntary HIV counselling and testing. This was expected to generate positive impacts in the fight against HIV, which was beginning to heave in the two African communities.
It is important to know one’s HIV status because it is considered the first step in accessing health care and preventing further infection with HIV and AIDS [5, 15]. Knowledge on test results enables an individual to initiate and maintain safer behaviors to prevent acquiring HIV and other sexually transmitted diseases (STDs) and, if found positive, to stop infecting others and gain early access to HIV-specific care, treatment, and support [2]. Additionally, voluntary counselling and testing for HIV have been established as one of the most effective strategies for early access to HIV and AIDS treatment, support, and care [2, 5, 6, 7, 10, 16–19].
Furthermore, a study conducted among healthcare students undertaking professional courses at certificates, diplomas, and degrees showed multiple responses with respect to sources of VCT information [20]. The commonest sources of information were from radios, televisions, friends, schools, church seminars, and VCT centers [20]. Most participants in that study held the view that VCT was important and enabled individuals to know their HIV status [20].
These authors suggest that information obtained from this current study could be used to strengthen information sharing among career professionals, and hopefully this would improve their VCT knowledge, and they become champion for VCT services in communities where they work. This was expected to have long-term and sustainability effects on VCT practices in their communities.
Furthermore, a comparative study conducted by Kalichman & Simbayi (2003) revealed that individuals who were not tested for HIV demonstrated significantly more AIDS-related stigmas, ascribing greater shame, guilt and social disapproval to people living with HIV and AIDS [21]. As previously seen, the problem of stigma has had profound effects on the fight against HIV in many communities in Africa [21]. It has been one of the drivers of HIV spread, mental health issues, and family problems, for example, domestic violence, separation, divorce, family neglect and unstable families in many communities in Africa [21].
These authors suggest a need for a comprehensive analysis on the root causes of stigma, its values, and concerns in the spread of HIV and AIDS in many communities in Africa. This is because most studies in Africa have shown stigma as one of the main drivers for poor participation in VCT services, treatment, support, and care for HIV-affected populations in many African communities.
Regarding attitudes in the current study, most participants had strongly positive attitude towards VCT (Table 3). Most respondents agreed that it was necessary to know their HIV status, although a minority were frightened to get tested and believed they had enough information on VCT (Table 3). Some participants believed that knowing their HIV and AIDS status was not beneficial because they feared the level of stigma they would go through in their communities in addition to the risk of divorce/separation from their spouses (Table 3). Similar findings were observed in [6, 7, 21], where stigma and fear of separation with spouses were cited.
These authors were mesmerized by participants who were afraid of taking HIV and AIDS tests for which they had no rock-hard reason for doing so (Table 4). This contrasts with a comparative study conducted in Nigeria among graduate students in a polytechnic school that found that 64.3% were ready to take a positive test result in good faith [14]. Their findings contrast with our current study, perhaps due to differences in sociodemographic characteristics, countries of study and differential advances in the spread and control of HIV in the two countries. Differences in the two studies were not new, as authors argue that these were behavioral and social sciences surveys where opinions and perspectives of individuals and communities change with time and were affected by circumstances, environment, study population and time of the survey.
Notably, a Ugandan 2000-2001 Demographic Health Surveys (DHS) found that 8.4% of women and 12.0% of men had tested for HIV with women in their 20s, and men aged 25-39 years, the most tested [22]. In addition, respondents living in urban areas, in Kampala district and those with secondary education were the most likely to have undertaken HIV counselling and testing [22]. However, among those who had not tested, 63.7% and 65.4% of women and men wanted to have a HIV test, respectively [22]. The report showed that many respondents were afraid of seeking HIV services because they feared stigma and discrimination by their families and communities [5, 6, 10, 23]. This information highlights the reason why VCT services should always preserve individual client’s confidentiality so that they do not suffer the distress of stigma in their communities [5, 6, 10, 23].
Studies have shown that if VCT services were properly carried out, they helped break the vicious circle of fear, stigma, and denials, which propagated the spread of HIV in many communities in Africa [5, 6, 10, 23]. Interestingly, in some circumstances, people asked for partners, relatives, and friends to be present during VCT processes, especially at the declaration of test results [23]. Furthermore, some participants preferred to receive their test results within the privacy of their homes [24]. Therefore, VCT could be promoted as a preventive measure and an entry point to support and care for those tested positive for HIV [24]. This has important implications that it could increase the number of couples attending VCT services in the fight against HIV and AIDS pandemics in their communities [23].
This finding is supported by a study conducted by the United States Centre for Disease Control and Prevention (CDC) and Uganda Virus Research Institute (UVRI), which found that the VCT model concentrating on home-based provision of counseling and receiving HIV test results was highly acceptable and greatly increased the proportion of those who received HIV test results compared to others [25]. These researchers suggested that their findings could be attributable to transport costs, which were often barriers to access to VCT, even though VCT services were freely offered in Uganda [25].
Furthermore, there were reportedly several psychosocial influences on women’s accessibility and utilization of VCT services more than men [26]. Partly, the psychosocial influence emanated from the community’s responses, personal beliefs, and attitudes towards VCT services [26]. Notably, the socioeconomic factors that could explain this vulnerability were that women were less mobile, had fewer economic possibilities for seeking treatment due to high transport costs to centers providing VCT services, unequal power relations whereby women often needed the approval of their husbands and family for health visits, and a low level of education among women [26].
In regard to VCT practices in the current study, most participants had good practices, reported having tested for HIV and AIDS, and encouraged others to undertake VCT (Table 4). This finding contrasts with a previous study conducted in Gulu in 2011, where only 36.1% of respondents had undertaken VCT, while 63.9% had not [5]. These authors argue that these differences in VCT practices were due to differences in the years when the two studies were conducted and ages of the study populations. Similarly, a study conducted in Rakai (Uganda) found that 93% (9,910 of 10,618) of respondents requested their HIV test results at the first instant [27]. Test result requests were higher among persons aged 15-24 years, those who had never married, persons with no formal education and persons who reported no sexual partners in the past six months [27]. In addition, there were no differences in test result requests between female and male respondents (93% and 94%, respectively). However, HIV test result requests were highest among persons who had prior VCT from the Rakai Program (96.1%) and among those with self-reported VCT results (95.7%) but lowest among individuals with no prior VCT (90.1%) [27]. Too, reported in the same study was that the uptake of VCT results delivered at home rose from 35% in the first year of study in 1994–5 to 65% in 1999–2000 [27]. Additionally, a study conducted in rural Uganda found that the overall VCT uptake among men was low at only 23.3% [28]. This finding was similarly observed in another study conducted in a black township in Cape Town, South Africa, where only 47% of participants self-reported having undertaken HIV tests [21]. These studies above show that VCT uptake in many communities in Africa have remained low, which may explain the rising incidence and prevalence of HIV and AIDS in many communities in Africa.
Additionally, a multicenter study conducted among university undergraduates in South Africa, India and the USA reported that only 20% of South Africans and Americans, and 10% of Indian students had undergone HIV testing [29]. Beguilingly, all these studies show that people who underwent VCT were fewer but were in better position to promote prevention and control of HIV. For these reasons, knowledge, attitude, hindrances, and practices on VCT among adults should always be assessed and analyzed appropriately to help design appropriate intervention measures for the affected communities in Africa.
It is important to note from this current study that improvement in knowledge and attitudes of participants on VCT services also significantly improved their VCT practices (Table 5, Table 6, and Table 7). The explanatory model derived from this multivariable regression analysis could perhaps be important in understanding and improving VCT uptake in this community, where HIV incidence and prevalence have steadily been rising for several years.
The implication of these findings is that in the long run, if this information is used appropriately by the Ugandan Ministry of Health, it could support improvement in VCT practices in this community, a place where prevention of HIV has become paramount. Curiously, this study confirms the long-held view in Uganda’s successful story for reducing the prevalence of HIV and AIDS more than any other African countries from a double digit to a single digit over the last two decades [30-35]. In the current situation of Northern Uganda, the incidence and prevalence of HIV and AIDS are increasing. These authors argue that Uganda ought to go back to the drawing board to reverse the downturn in the increasing incidence and prevalence of HIV and AIDS, and maintains the gains achieved over the years.
In the 2020 report released by the Uganda AIDS Commission (UAC), Gulu District had the highest prevalence of HIV and AIDS in Northern Uganda [9]. At 14.0%, the prevalence rate of HIV in Gulu was higher than the national average at 6.0% compared to Northern Uganda’s statistics, which stood at 7.0% [9]. In addition, the UAC report showed that HIV prevalence in Northern Uganda was higher in females at 17.1% than in males at 8.0%. Accordingly, the UAC report showed that higher prevalence of HIV in Gulu District and Northern Uganda in general was attributable to many factors, for example residents having multiple sexual partners, low uptake of safe male circumcision, high level of community stigma, enormous poverty among the population and many other reasons, such as poor traditional practices and beliefs, wife inheritance, immense youth unemployment, and rapid urbanization, which have led to increased population, poor lifestyles, and poor social determinants of health in the region [9].
Therefore, in the 2020 UAC report, the District Health Officer of Gulu District reported that there were 27,000 people living with HIV in the district [9]. However, he revealed that many persons reported to be living with HIV and AIDS in Gulu were from neighboring districts but receive their antiretroviral drugs (ARVs) from Gulu District, particularly from Gulu Regional Referral Hospital, TASO Gulu and St. Mary’s Hospital, Lacor. He argued that this may in part explain the reported high prevalence of HIV in the Gulu District because the district was the regional hub of the region [9].
These authors contend that HIV and AIDS prevalence challenges in Gulu District were enormous. To address issues of high HIV prevalence, there was need to address VCT knowledge, attitudes, and practices in the community. To increase VCT uptake in this community, knowledge, attitudes, and confidentiality of VCT reports were critical. This was because stigma to persons living with HIV and AIDS (PWLHAs) would reduce people's willingness to have themselves tested for human immunodeficiency virus (HIV), thereby reducing the number of people who openly declare their HIV status and thus increase the risk of HIV transmission in communities since most sufferers would go underground.
Strengths and limitations of this study
This was hospital-based data derived from patients attending outpatient clinics at Gulu Regional Referral Hospital, and information generated should be interpreted in the context of a hospital setting. This may have created selection biases, as all information obtained were from patients, and this may not reflect accurate information from the general population of Gulu and northern Uganda. Moreover, data were obtained from only one regional hospital. However, as observed, the diversity of participants cutting across different sociodemographic characteristics, for example, gender, age, occupation, and tribes, give strength and diversity of information obtained, which were similarly observed in previous studies conducted in the region. Of interest was that GRRH is a public hospital that offers free health services to every person. The hospital has general outpatient and specialized clinics that offer unlimited access to medical services. The free medical services offered at GRRH may have reduced barriers to access to participants we interviewed and therefore a strength for this study.
Second, the questionnaire we used was not derived from a validated questionnaire to determine knowledge, attitude and VCT practices of participants however, we pretested the questionnaire in a nearby hospital, and the internal validity was Cronbach’s α = 0.71, which was acceptable for the information we obtained.
Generalizability of these results
The results from this study could be generalized to most hospital-based data in Uganda, especially regional hospitals that are situated in cosmopolitan urban centers in Uganda.
