To our knowledge, this is the first study to determine WTP for STI screening tests among husbands accompanying their pregnant wives at ANC clinic whereas other studies have explored this among men who have sex with men, commercial sex workers, as well as voluntary counseling and testing clients as shown in Table 1. Three contingent valuation methods have commonly been used to find the WTP price for STI screening tests. The payment scale method suggested a lower cost while the open-ended and bidding methods suggested similar WTP prices for STI screening tests. Husbands who accompanied their pregnant wives at the ANC clinic of our institution showed the WTP at least two times of the hospital price for STI screening tests.
In our study, based on the bidding method, the husbands were willing to pay US$14.5 and US$9.7 for HIV and syphilis screening tests, respectively while the payment scale method suggested lower WTP for both (US$10 and US$7.4). However, previous studies showed lower WTP prices among high-risk populations for an HIV test: US$5 in Peru14, US$7.75 in Vietnam15, US$2 in Kenya16 and US$4.8-8.1 in China17. The general population in China was willing to pay US$818 and students in Kenya US$3.2.19 The WTP prices for an HIV screening test varied across studies may be because of different HIV prevalence, health literacy level, and socio-economic factors.
While previous studies explored the WTP value for only one disease, this study explored the WTP prices for HIV and syphilis screening tests simultaneously. As the HIV/AIDS is perceived by a layperson as relatively more severe than syphilis so the WTP amount should be reflective, this study showed the higher WTP price of HIV than that of syphilis screening tests, suggesting good reliability of the findings.
In Thailand, the HIV screening test has been financially supported by the Thai Universal Coverage Scheme since 2009; the pregnant women and their husbands who attend ANC service at any public health care facility will receive HIV screening test free of charge two times per year. Husbands who accompanied their wives to attend ANC service are not only considered ‘family men’ but also financially viable and have time to spend with the loved ones, suggesting a lower risk of STI than those at lower socioeconomic status. Therefore, government subsidization of the laboratory expenses should be for the poor and/or high-risk.
In this study, 88% of the accompanying husbands were willing to test for STIs. This is similar to other studies. Batte et al conducted a survey in Uganda and reported 98.9% of pregnant partners to receive CHTC whereas only 42.4% were tested when coming separately.20 Moreover, Thirumurthy et al in Kenya attributed HIV self-testing of partners through pregnant women; the result showed 91% of the pregnant women gave the self-tests to their partner but only 51% were tested,21 suggestings that husbands tended to receive HIV testing when they were approached as a couple.
History of STI test was significantly associated with willingness to test; Xu et al reported the association between history of STI testing, education, risk behavior and willingness to test among men who have sex with men and female sex workers.14 The associated factors may be different across population groups. Batte et al in Uganda reported the significant association between the number of ANC services and willingness to test20 but this study surveyed only the first ANC visit so the impact of ANC visits could not be investigated.
Barriers to STI screening at our ANC clinic were similar to previous studies. Musheke et al, for example, reported self-perception of no risk, fear of secret being revealed, stigma, cost of STIs testing and gender equality.22 In Thailand, Lolekha et al conducted a survey in the pilot CHTC program and revealed that the husbands of pregnant women who were unwilling to test for STI reported self-perception of no risk, intention to be tested at another facility, fear of the needles, and already know their HIV status to be barriers to STI screening uptake.8 Our study showed 44% of husbands who received STI testing previously and 88% were willing to test with their pregnant wives. According to the propitious selection theory, supported by our findings, husbands who accompanied their wives to ANC services were more likely to cooperate with the CHTC program.
Some limitations should be noted. This study was conducted at an ANC clinic of a tertiary care hospital and all data were collected from randomly selected husbands of pregnant women receiving their first ANC service so the findings might not be generalizable to other settings. Husbands who participated in the study may be more willing to cooperate and able to pay for their STI screening tests than those in lower socioeconomic contexts. We did not have information about one-third of husbands who did not come to the ANC clinic and might be of lower socioeconomic status and/or less health concerned. The study was conducted at a university hospital, thus not representative of Thailand, as Bangkok populations, in general, have higher incomes than those in rural areas. Additionally, individuals who come to university hospitals usually agree to pay medical care costs out-of-pocket as opposed to patients who go to Ministry of Public Health hospitals under the Universal Coverage Scheme. For further studies, the survey should be conducted at multiple ANC service settings nationwide. To represent the general population, the survey should be done in husbands attending and not attending ANC services with their pregnant wives. Also, the survey should cover all population groups to provide better evidence policymakers to allocate more resources to people who have higher risk but lower ability to pay. For the reliability of the willingness to pay, comparing two diseases and two contingent valuation methods are recommended.