Promotion and Persistence of HIV Testing and HIV/AIDS Knowledge: Evidence from a Randomized Controlled Trial in Ethiopia

We have three types of interventions: door-to-door HIV/AIDS education, home-based voluntary HIV counseling and testing (VCT), and CCT for facility-based VCT.

The Door-to-door HIV/AIDS Education session consists of a HIV/AIDS information session and a provision of VCT poster. HIV/AIDS information session addressed ways of HIV transmission, the advantages (and potential problems) of HIV testing, ways of learning one’s HIV status in the study area, and access to AIDS and other medication that can reduce the risk of mother-to-child HIV transmission. At the end of the information session, HEWs handed out a poster (per household) that promoted VCT and placed it in a visible place inside the residence.

Health Extension Workers (HEWs) offered a free home-based VCT and, if interested, made appointments between 9am and 5pm in the following 10 days. Community-based VCT providers, known as Community Counselors (CCs), from nearby districts visited eligible subjects per the appointment set by HEWs. They conducted HIV testing in line with Ethiopia's guidelines for HIV counseling and testing and under the condition of the “Three Cs”: informed consent, confidentiality, and counseling. Pre-test counseling, HIV testing, and post-test counseling (and test results) were all carried out in a single visit and in private (to couples). Testing was conducted by using rapid test kits and finger-prick blood samples.

Cash incentives were to compensate for the cost of round-trip transportation and a day of lost farm wages due to a trip to an assigned testing clinic in the capital of Hetosa. Coupon values ranged between 1.5 and 2.9 U.S. dollars, depending on the distance between the study willage and the assigned testing clinic. HEWs informed participants that they would receive cash compensation if they wished to learn their HIV status. If interested, HEWs handed out coupons (one per eligible individual) and explained the conditions for coupon redemption. Coupons were non-transferable and redemption was conditional on subjects learning their HIV status at the assigned testing clinic before coupons expired in 10 days. HIV counseling and testing at the clinic was carried out in the usual manner and free of charge.

2010-04-01

2010-11-30

Main outcome variables include 1) HIV/AIDS knowledge, and 2) HIV test take-up.

An indicator of HIV/AIDS knowledge was constructed based on six questions about whether the individual is knowledgeable about the fact that abstinence, being faithful to one's partner, and the consistent use of condoms (the “ABC” of HIV prevention) reduce the chance of HIV infection and that HIV can be transmitted from a mother to her child during pregnancy, delivery, or breastfeeding. Response options were coded as ``agree with'', ``disagree with'', and ``do not know'' and they were rescaled to an indicator that takes one if the respondent agrees to a correct sentence and zero if the respondent either disagrees to a correct sentence or states ``do not know''. An HIV/AIDS knowledge score was then constructed by taking the fraction of correct responses. For the regression analysis, the knowledge score was normalized with reference to the control group.

HIV testing take-up information was derived from administrative and survey sources. Administrative testing data refer to HIV testing status in response to the two rounds of intervention we offered (home-based VCT and cash incentives). Self-reported testing data refer to the data on testing status we collected during the follow-up surveys, regardless of whether the testing was in response to the incentives we provided.

In the first round experiment, the three treatment groups (Groups 1 to 3) were offered three (overlapping) treatment arms: door-to-door HIV/AIDS education (Group 1), door-to-door HIV/AIDS education and home-based VCT (Group 2), and door-to-door HIV/AIDS education and CCT for facility-based VCT (Group 3). The control group (Group 4) was not offered any treatment during the first-round experiment.

For the second round of intervention, we re-randomized eligible households in the four research groups from the first-round experiment (Groups 1 to 4). Each of the four groups was randomized into two equal groups with the first sub-group offered free home-based VCT and the second sub-group offered cash incentives for facility-based VCT.

Randomization of household in office by computer random number generator

Household level

Yes

1,658 individuals in 959 households were eligible to participate in this study. We successfully interviewed about 90% and 81% of study participants in the first and second follow-up surveys, respectively.

1,658 individuals

1) First round intervention
G1 (HIV/AIDS education only): 328 individuals in 192 households
G2 (HIV/AIDS education + Home VCT): 343 individuals in 192 households
G3 (HIV/AIDS education + CCT for facility VCT): 329 individuals in 192 households
G4 (Control group): 663 individuals in 384 households

2) Second round intervention
Home VCT: 692 individuals in 554 households
CCT for facility VCT: 653 individuals in 532 households