Trends of HIV/AIDS Infection in Arsi Zone from 2002-2008 E.C (2010 to 2016 G.C), Oromia Region Ethiopia: Evidence from VCT Registry

Introduction: HIV continues to be a major global public health issue, having claimed more than 35 million lives so far. Globally, about 36.7 million people living with HIV currently, more than two third of the infection is the burden of Sub-Saharan Africa. Knowing the status of HIV/AIDS has the great value to individual health of treatment with ART and in terms of reductions in individual morbidity and mortality, and is equally cost-effective. Therefore, the aim of this study was to assess trends and associated factor of HIV infection in Arsi zone from 2010 to 2016. Methodology: A retrospective study was conducted in Arsi zone. Thirty health facilities (27 health centers and 3 Hospitals) were selected for the study from all woreda in the Zone. A total of 205,691 data was collected from VCT registration book. Data were entered into computer using Epi info 3.5.4 and exported for analysis to SPSS 21. Data were presented using tables and gures using line graphs. Logistic regression was used to see the association and signicance was declared at P-value<0.05 Result: The study showed a total of 4300 HIV positive cases were reported between 2002(2009 G.C) to 2008(2016 G.C) according to available VCT registration book during survey at 30 health facilities. The trends of HIV of infection were not properly dened, it was 3.4% in 2002(2010 G.C ) and mean while a gradual drop has been observed in the next ve consecutive years, almost which was less than 2% prevalence and in 2008 the prevalence was raised to 2.4% compared to 2007 and before. The changes in HIV prevalence were uneven among districts. Findings from logistic regression analysis indicated that the tted demographic characteristics like, marital status, age and occupation were signicantly associated with HIV positivity in both bivariate and multivariate analysis. Conclusion: There are no encouraging indications that the HIV prevalence has decreasing since there were variation among districts. Therefore there is a need of designing comprehensive strategy to combat the spread of HIV infections among all individuals. It is also important to strengthening VCT services at all level with strict follow up.


Introduction
The acquired immunode ciency syndrome (AIDS) since its rst recognition among ve homosexual men in the United States, Los Angeles in 1981 and continually a major global Public Health issue, having claimed more than 35 million lives so far (1)(2)(3). The AIDS epidemic now ranks alongside the in uenza pandemic of the early 1900s and the Bubonic plague of the 14th century in terms of fatalities (1).
Globally currently about 37.9 million people living with HIV, 1. Under Sustainable Development Goal 3, the global community has agreed to aim to end the AIDS epidemic by 2030 (6), and under the UNAIDS "90-90-90" targets, countries work toward achieving, by 2020, "90% of people living with HIV knowing their HIV status; 90% of people who know their HIV-positive status on treatment; and 90% of people on treatment with suppressed viral loads (5).
AIDS is now affecting all sectors of Ethiopian society. The future course of the AIDS epidemic in Ethiopia depends on a number of factors including HIV/AIDS-related knowledge, social stigmatization, risk behavior modi cation, access to high-quality services for sexually transmitted infections (STIs), provision and uptake of HIV counseling and testing, and access to antiretroviral therapy (ART) (7,8).
The geographical structure of HIV epidemic is the consequence of drivers of the epidemic and the availability of susceptible population to the infection, strongest clustering has been observed in countries with a low national prevalence of HIV infection. The 'know your epidemic' concept recognizes this geographical feature as a key strategy in identifying populations at higher risk of HIV infection and in which prevention interventions should be targeted (9).
As with all generalized HIV/AIDS epidemics, heterosexual transmission is the primary mode of HIV transmission in the region and female commercial sex workers (CSW) remain a key population for HIV prevention efforts. Within Africa, the potential importance of men who have sex with men (MSM), in terms of enhanced HIV transmission among MSM sexual networks and 'bridging' into heterosexual sexual networks, is only now being recognized and MSM research remains in its infancy (10)..
The current moment is one of great optimism in HIV prevention. Breakthroughs in HIV treatment, prevention science, program implementation and human rights realization have led to assertions that "an AIDS free generation" is possible that Advances in HIV prevention (11).
The main drivers of the epidemic to explain the overall trends in the country have not been described. It is also not known whether the main transmission determinants differ by sex or differ between rural and urban areas. Understanding the direction of the change in HIV prevalence, along with various drivers of HIV transmission in different populations and areas of the country, is of paramount importance in intervention design, evaluation, and scale-up, [UNAIDS and WHO 2011].
The impact of HIV/AIDS on human suffering, cultures, demographics, economics, and even politics has been felt in nearly every society across worldwide. Monitoring a localized HIV/AIDS epidemic is important for more effective prevention strategies. In Ethiopia even though adult HIV prevalence has declined at the national level, little information is available about the sub geographic areas and certain subpopulation groups in the country. Majority of the individual studies conducted HIV/AIDS previously emphasis on prevalence and risk factor at a point time(), did not indicated the trend for many years HIV infection using large sample size. The nding of this study would indicate the past and current infection rate in Arsi Zone that might help program planners to design and integrated prevention and control strategies. Therefore, this study was intended to assess the trends and Associated factors of HIV infection in Arsi zone from VCT Registry from 2010 to 2016 in Ethiopia.

Study setting
The study was undertaken in Arsi Zone Oromiya regional state from May 2016 to October 2016. The zone shares boundaries with East Showa, West Hararghe, Bale and West Arsi Zones. Asella is the capital town of Arsi Zone, which is located 175 km South East of Addis Ababa capital of the country. Based on 2007 Housing and population census projection, the total population of Arsi is projected to be 3,280,667 million in 2016, of which 90% of the population is estimated to be rural residents. Administratively, the zone is divided into 25, woredas and 2 administrative towns having an area of 23,679.7 km 2 .The average altitude ranges from 1700 to 4000 meters above sea level. The average temperature varies from 10 to 24 0 C.

Study design
Health institutions based retrospective study design was employed to extract data from VCT registry.

Study population
All clients registered on VCT registry book from September 2002 to August 2008 from those selected health facilities (Health Center and Hospital) were included.

Exclusion Criteria
Records that did not have complete information especially on the test result relevant for the study.
Sample size and Sampling procedure: All participants with complete information from the registry book were included from September 2002 to August 2008 E.C. About, two hundred thousand six (205,691) participants were included. From 100 health centers found in the woreda, 27 health centers (Health Centers located in the woreda town) and 3 Hospitals were selected purposively those giving ART and VCT services.. The majority of health centers found outside the district town were established recently (< 5 years) and they were not delivering ART service and have no organized VCT registration book during the assessment. Data collectors were oriented how to ll the questioners from the registry. The completeness of the lled questionnaires were randomly selected and cross checked with the information VCT registry.

Statistical Analysis
The variables were coded and entered into computer using EpI info version 3.5.4 software by data clerk and then transported to SPSS version 21 software for Analysis. Data was Cleaned and checked for missing values, outliers and for any inconsistency before running the analysis. Descriptive statistics using frequency and percentage was used to describe the pattern of occurrence of HIV infection. Cross tabulation was done to see differences between different characteristics. Row total was taken to know percentage. Logistic regression was used to identify some of sociodemographic predictors of HIV infection and difference of HIV prevalence between Health facility. Odds ratio(OR) both Crude and Adjusted odds ratio with 95% con dence interval(CI) at P-value less than 0.005 was considered to declare signi cant association. After obtaining percentages using SPSS, Microsoft o ce Excels Worksheet on a window 2010 was used to show trends of HIV infection.

Ethical consideration
Support letter was obtained from Arsi University College of Health Sciences, Research and community service coordinator and submitted to respective health facilities. Since data were extracted from registry, no need of further informed consent from the participants since code was used to represent individual information in the registration book.

Page 6/25
Socio-demographics Characteristics of the Respondents A total of 205,691 data were collected from the 30 selected facilities from available registry. The detail of information is presented below in Table 1. were Muslims (Table 2).  The prevalence of HIV was high (3.4%) in 2002, mean while a gradual drop has been observed in the next ve consecutive years, almost which was less than 2% prevalence and in 2008 the prevalence was raised to 2.4% compared to 2007 and before.
As depicted in the Fig. 1   magnitude was observed for three years which was 1.6%. It is also substantial proportion of age above 64 were affected by the epidemic in the last seven years (Table 5).  Figure 3 shows the pattern of HIV occurrence among VCT attendants in relation to age. The patterns in HIV incidence in various age-groups were not well de ned, which showed a decreasing a among young ages until 2007 and raised in 2008 and among older group the incidence as general high and showed a mixture of peak and down at different years but in all peaked in 2008.

Association of HIV infection with Socio-demographic factors
Socio-demographic characteristics like marital status, sex, occupation and age were included in bivariate and multiple logistic regressions to see the association with HIV/AIDS infection. All these characteristics showed that signi cantly associated with HIV infection in the bivariate analysis, meanwhile to control confounding effect all these variables were entered together in the multiple logistic regression they were also signi cantly associated.
With regard to gender relation with HIV infection, in this report females were more likely to be HIV positive   Center, Arboye Health center and Abomsa Health center have no data from 2 to 3 years.
High prevalence of the infection was seen at Eteya, Robe and Bele Health centers which was more 2% and in majority of facilities the epidemic curve showed a steady increasing, but in contrast of this at Sagure Health center, the incidence of HIV infection is decreasing. For detail, the information for each health facility is presented as follow separately in tables to show the magnitude of problem (under supplementary information).

Discussion
The spontaneous spread of the HIV is a worldwide health challenge since its discovery before three decades and has lasted a great devastating consequence on socio economic growth. Globally the pandemic of HIV is becoming lesser, but still there is a substantial effect of the diseases at different segment of population especially those living in developing country. In our country context, as general report there was a drastic fell of HIV infection, but still there is no individual report that re ect speci c area intensively. There is also a problem of handling reports (data) properly for a long time for the area which will help to trace the magnitude of the problem when needed. The reason why we conducted this study was to see and slightly decreased in 2007 to 1.6% and the incidence raised above 2% in 2008. The global, regional and National reports also indicated that a decrease of the incidence of HIV/ infection. For example according a global report on HIV/AIDS by UNAIDS, there was large reduction the infection was observed in eastern and southern Africa (5). But in the study area prevalence is still high compared to the national ndings as explained earlier.
As general there was a gradual decline of HIV infection, still there are disparities of the prevalence of HIV/AIDS among districts (health facilities), districts like Robe, Abomsa, Kersa, Dera, Assela, Eteya, Aseko, Huruta, Ziway dugda, Bokoj were considred as hot spot areas for the prevalence of HIV infection. According to report of UNAID 2016, globally the magnitude of HIV infection. showed a downfall, but there is country, regional differences(5).
Factors associated with HIV positive was assessed, accordingly in this study signi cant association was observed among marital status with HIV positivity. The risk of HIV infection was higher among formerly married (widowed/divorced/separated) (AOR = 2.43, 95%CI = 1.99, 2.98) compared to single. Though the strength of association is moderate, the likelihood of HIV positive was 1.43 times more likely among currently married and in union compared to unmarried ones (AOR = 1.43, 95%CI = 1.21, 1.70). Consistent with this study the study conducted in Nairobi Kenya reported that, this risk of HIV/AIDS was higher among widowed compared to unmarried (12)(13)(14). The attribute could be due to, the reason for their divorce and separation could be one of the partner might be affected by HIV infection or He she might have risky behavior. Whilst for widow, the cause for the death of the former partner could be related with HIV/AIDS.
Our study also showed that married individuals were at risk of getting HIV infection compared to unmarried (15). The justi cation for this association could be spouses are likely to enter into relationships without knowledge of each other's HIV status or with no interest to know their self and spouses HIV status even after marriage. In other context married individuals are less likely to use HIV prevention strategies including condoms and HIV counseling and testing services, especially when one of the spouses is not faithful.
With regard to the effect gender on being HIV positive, in this study females were more likely to be HIV positive than their counterparts. This is in line with different studies conducted in Ethiopia (16,17). Evidences re ecting that a range of factors contribute to the vulnerability of women to the HIV virus. Women are victims of discrimination in the economic, social and political life of the community which factors may directly or indirectly contribute to their exposure to HIV/ AIDS. Many of them are also subjected to different kinds of violence's including sexual violence, harmful traditional practices like female genital mutilations which increase their chance of HIV infection (18),nature of their reproductive biology that increase the retention of viruses in their body compared to men (19,20).
Occupation showed that an association with the HIV positivity. A signi cantly strong association of HIV positive was observed among commercial sex workers.  (22,23). The proposition of this nding that the longer survival of people living with HIV and the ageing of the HIV + population. This is also pointed as that people visit health facility (seek screening) when they suspect their selves as being infected if they were contacted sexually with person pass away and be panic for screening. Other than this, other this when their health is disturbed after the consequence of advanced stage of HIV/AIDS, after long stay with infections.
One of the limitations of this study was not including, PMTCT/ ANC data which is one of the three methods of data used for assessing trends of HIV/infection, due to pre assessment of uavailability of fully recorded registration and to avoid some overlapping as possible. The trend did not indicate by rural and urban due to no information available in the registrations. In some cases case may be retested, but we have tried to ignore those individuals tested previously from the registrations. So, considering this limitations it is better to cautiously interpret this ndings. Though the study has its own strengths; use of a large sample laboratorycon rmed HIV serostatus records. It might be the rst time in the study area as well as probably in the country and elsewhere as far as our knowledge. Therefore, the nding from this study will be used to as a source of information to governmental and nongovernmental policy makers to evaluate their programs.

Conclusions
This analysis showed that the trend of HIV infection in Arsi zone showed a slight decreasing before 2016 and moderately increased in 2016 even though the VCT was not fully provided due to shortage of Kits for test at national level. The incidence of HIV was high among older group population compared to the younger. The changes in HIV prevalence were variable in some districts. Findings from logistic regression analysis indicated that demographic characteristics like, marital status, age and occupation signi cantly associated with HIV positive, after controlling the confounding effect.
Based on the nding of this study, there are is no encouraging indications that the HIV prevalence has decreasing since there was variation among districts. Therefore there is a need of designing strategy to combat the spread of HIV infections, so we have forwarded the following recommendation for Arsi university, Zonal health department and woreda health o ces, Ministry of Health and other concerned stakeholders with HIV program and related to tackle or to make zero prevalence of this public health importance issue as follow; For Ethiopian Federal Ministry of Health; Working with partners to improve the uptake of VCT services at all level.
Strengthening the VCT services properly with close follow up of the activities being done. Improvement of the HMIS VCT registration book to include other important socio-demographic characteristics like marital status, educational status occupational status and others which are important comparison variables.
Monitoring the epidemics of HIV in accordance with subpopulation segmentation and localized intervention programs would have a vital importance rather than using the national prevalence as the key monitoring variable.
More prevention campaigns should be intended and carried out while matters arising with increasing access to HIV testing, counseling, ART and care should be accessed.
UN and other Organizations Re-strengthening their funding and technical support for developing country like Ethiopia to run the programs of HIV/AIDS service, including VCT service uptake improvement.
Designing ngerprint identi er, to avoid some overlapping to determine the true incidence to avoid some social desirability bias and lies during incase of re-testing. Our special thanks go to Arsi University for its limited nancial support for the project activity during eld work. It's our great pleasure to appreciate data collectors and data clerk for their precious time investment for this project. Finally we thank Woreda health o ces and health facility leaders for their cooperation.

List Of Acronyms
Authors' contributions MTS had substantial contribution; did conceptualization of the study, design, analysis and interpretation of the data as well as manuscript preparation. HF has made substantial contributions on the analysis and interpretation of data and participated in the critical review and editing of the manuscript drafts for scienti c merit and depth. MA and HT have been involved in analysis, interpretation of data and revising it critically for important intellectual contents. All authors read and approved the nal manuscript.

Funding
Limited fund was obtained from Arsi University.

Availability of data and materials
Additional detailed information and raw data will be shared upon request addressed to the corresponding author.

Ethics approval and consent to participate
The required data were collected after obtaining ethical clearance from Arsi University College of Health Science Ethical Review Committee. In addition support of letter was written to Arsi Zone Health O ce to get permission then the zone wrote letter to respective districts to give support during data extraction.

Consent for publication
The Author declares that contributed in this work are aware of the fact and have agreed to be named in the manuscript. The Authors guarantees that the Work has not been previously published elsewhere. All authors read and approved the nal manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.