Why Might Clinicians in Malawi Not Offer Hiv Testing to Their Patients

WHY MIGHT CLINICIANS IN MALAWI NOT OFFER HIV TESTING TO THEIR PATIENTS?

Corey Lau MD1, MS; 2Adamson S. Muula MB BS, MPH; 3Humphreys Misiri, Msc;

3Tilera Dzingomvera MB BS and Gregory Horwitz PhD, MS,

1Current: Department of Epidemiology, UCLA School of Public Health, Los Angels, CA, USA

Prior: Department of Internal Medicine, Blantyre Adventist Hospital, Blantyre, Malawi

2Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi

3Out-Patient Clinic, Blantyre Adventist Hospital, Blantyre, Malawi

4Vision Centre Laboratory, Salk Institute for Biological Studies, La Jolla, CA, USA

ABSTRACT

Context: HIV testing may be a cost-effective means of reducing transmission rates. Since Malawi is severely impacted by HIV/AIDS and detection of infected persons is sub-optimal, reasons clinicians might not offer HIV testing to their patients should be identified.

Objective: Identify common reasons clinicians in Malawi might not offer HIV testing to penitents

Design, Setting and Participants: Cross-sectional, descriptive, postal survey techniques with telephone and fax follow-up were used to collect a census of clinicians in Malawi. Basic demographic information and reasons one might not offer an HIV test were solicited.

Main Outcome Measures: Proportions were calculated for each reason for not offering HIV testing. Multiple logistic regression was used to determine whether responses differed by demographic characteristics. A p-value of <0.05 was considered significant.

Results: 523 of 982 (53.26%) registered clinicians responded. Mean age of respondents was 43.56 +/- 12.93. The five most common reasons for not offering HIV testing were: inadequate training in HIV counseling (50.29%); perception that patient not ready to be tested (49.52%); no indication for testing (35.56%); testing facilities unavailable (35.37%); and insufficient time for testing (28.87%). Of six medical professional cadres/ categories, medical assistants were most likely to give the reason inadequate training in HIV counseling (p=1.1200 x 10-8, _ coefficient = 1.2693 ± 0.2290).

Conclusions:

Though differences in reasons for not offering HIV tests amongst clinician groups were small, medical assistants report lack of training in HIV counseling as a barrier to HIV testing more than other groups. Thus development of one general program based on common reasons identified in this study, with a subcomponent to educate medical assistants on HIV counseling, could be effective in increasing HIV testing rates. Further investigation of the identified reasons should be undertaken to facilitate program development.

BACKGROUND:

HIV/ AIDS is a major global health concern. Over 42 million people were estimated to be infected with the virus world- wide. Sub-Saharan Africa, where at least 29 million people were infected at the end of 2002, is the region with highest prevalence.

It is estimated that at least fifteen percent of Malawi’s adult (15-49 years old) population is HIV infectedii. The country is therefore amongst those that have been hardest hitiii,iv. For example, HIV infection is responsible for the upsurge in the number of tuberculosis (TB) cases, pneumonia, sepsis, Kaposi’s sarcoma and other cancers in Malawiv,vi,vii. Furthermore, mortality is higher amongst children with HIV positive parentsviii. Unfortunately, diagnosis of HIV usually late in the disease, when symptoms and AIDS defining-illnesses are already present.

Benefits of early HIV diagnosis have become increasingly apparent with recent treatment advancesix. A short time ago, diagnosis of HIV sero-postivity resulted only in disheartenment due to lack of effective therapy. Even in the private sector where at least some could afford drugs, particularly anti-retroviral therapy (ART), the outlook for HIV positive persons was dismal. Presently, ART has been made more accessible at a number of private hospitals, and even at selected public health institutions.x At end 2002, 1220 patients in Malawi’s public health sector were receiving ART (904 in Blantyre and Lilongwe, 316 in Chiradzulu).xi The Ministry of Health and Population plans to increase accessibility to ART through the Global Fund HIV/ AIDS Programs.xii Other measures to improve ART availability are Church of Central Africa Presbyterian (CCAP) Blantyre Synod Initiative through a donation from Pittsburgh Presbytery and involvement by non- governmental organizations, for example Medicins Sans Frontieres (MSF).xiii

Studies suggest that worldwide screening levels for sexually transmitted diseases, including HIV, are well below practice guidelines.xiv,xv For example, a survey of members of the American Academy of Pediatrics found that 42.5% of pediatricians do not counsel pregnant women or mothers of newborns on HIV screening.xvi Peters et al reported that missed opportunities for perinatal HIV prevention contributed to more than half of the cases of HIV infected infants.xvii However, implementation of an opt-out prenatal HIV testing policy results in a dramatic increase in the number of females being tested for HIV infection.xviii Furthermore, education of health care providers has been shown to dramatically increase testing rates.xix,xx,xxi

Ethical dilemmas associated with HIV testing may prevent health care workers from offering testing and may also inhibit patient acceptance of testing.xxii,xxiii In the United States, New Zealand and Zimbabwe, surveys have revealed several reasons physicians might not offer HIV testing to patients: perceived reluctance to be tested, lack of time, knowledge deficit, insufficient support services, disinclination to inform a patient about positive sero-status and fear of traumatizing patients.xxiv,xxv,xxvi However, HIV testing is a cost-effective approach for preventing HIV infection.xxvii,xxviii In addition , routine screening is likely more cost-effective than testing based on medical history.xxix

Knowledge about HIV status informs possible management options on the part of both patients and health care workers. If clinicians do not offer HIV tests to their patients, the benefits of HIV serostatus knowledge may be forfeited. Furthermore, benefits of early diagnosis and treatment options, such as Highly Active Antiretroviral Theraphy (HAART) for HIV, contrimoxazole prophylaxis against Pneumocystic carrinii pneumonia and Fluconazole for Cryptococcal meningitis, continue to increase. Since Malawi is so severely impacted by the HIV/ AIDS epidemic and identification of infected persons is sub-optimal, measures must be taken to increase HIV testing rates. Patient-clinician interactions are an invaluable and under-utilized opportunity for testing.

In this study, clinicians registered with the Medical Council of Malawi were surveyed to identify reasons for not offering HIV testing to their patients. Differences in reasons amongst clinician subgroups were also assessed. Elucidation of these reasons will hopefully facilitate development of targeted interventions to increase rates of HIV testing, thus improving management of sero-positive individuals and potentially decreasing rates of HIV transmission.

METHODS:

Technique:

This was a cross-sectional, descriptive postal survey with telephone and fax follow-up.

Study Population:

All clinicians registered with the Medical Council of Malawi were recruited to participate in this study. This group included specialists, general practitioners, dentists, clinical officers and medical assistants from both public and private practices. Clinical Officers and Medical Assistants comprise the largest groups of clinicians in Malawi.xxx

As the annually published Medical Council of Malawi Registry may be incomplete, clinician names were also requested from district and mission hospitals and surveys mailed to those people. Clinicians who were out of the country during the study period, deceased or retired were excluded from the census. A total of 982 eligible clinicians were identified.

Survey Instruments:

Instruments designed by the study authors were used to assess reasons for not offering HIV testing. All surveys included instructions to print clearly and asked several basic demographic questions. Following the demographic questions, participants were asked to tick choices corresponding to and/ or write in their reasons for not offering HIV testing. The survey is shown in Figure 1. An informed consent sheet accompanied each survey. Return of the survey was considered indicative of willingness to participate in the study. Ethical clearance was obtained from the College of Medicine Research and Ethics Committee (COMREC).

Data Collection:

Postal survey techniques with telephone and fax follow up were used to collect a census. Surveys were mailed to clinicians in May, 2003. A pre-addressed stamped envelope was included to facilitate return by post. After one month non-responders were contacted by telephone. Telephone numbers listed on the Medical Council of Malawi registry, with district health offices and in the Malawi Telecommunications Limited directory were used. When the clinician was unable to complete the survey via telephone, the survey was faxed to the clinician and returned by fax to Blantyre Adventist Hospital.

Analysis:

Survey data was entered into a Microsoft Excel spreadsheet. To account for use of different wording in the written response section, written responses from respondents were grouped according to reason for purposes of analysis.

In order to eliminate census bias due to non-response, population weighting was used to evaluate the effect of non-response related to profession.xxxi Proportions were calculated for each listed reason for not offering HIV testing to patients. Multiple logistic regression techniques were used to determine whether response differ by respondent age, gender, citizenship or profession.xxxii The fitted was of the form: log [p/(1-p)] = _ 0 _1 (age) +_2 (gender) + _3 (citizenship) + _4 (specialist) +_5 (general practitioner) + _6 (medical assistant) + _7 (dentist) + _8 (Other profession).

Each of the 16 reasons for not offering HIV testing was modeled independently. Clinical officers comprised the largest profession proportion and were therefore used as the referent group. S-plus statistical package was used for analysis.xxxiii Statistical significance was assessed with likelihood ratio tests, A p-value of <0.05 was considered statistically significant.

RESULTS:

523 of 982 clinicians (53.26%) responded to the postal survey. Demographic characteristics of respondents are shown in Table 1. Average age respondents was 43.56 +/- 12.93 (mean +/- standard deviation); average age of the surveyed population was 46.90 +/- 12.28. Respondents were overwhelmingly males and Malawian citizens (91.22% and 91.20%, respectively). 39.34% of respondents were in private; 40.84% were trained in palliative care; 55.38% had HIV testing available through their practice; 22.46% worked at facilities offering HAART; 66.47% worked at facilities with a trained HIV counselor; and 45.05% reported that their facility was associated with a home based care program.

In Table 2, the reported professions of respondents and profession distribution for the registry of the Medical Council of Malawi are shown. Distribution of professions was different between respondents and the surveyed population; medical assistants were under-represented and clinical officers were over-represented in the sample.

Reasons given for not offering HIV testing to patients are shown in Table 3. In addition to the eleven suggested reasons, the following five were included based on written responses: no facility available, no ARV available, non-conducive circumstances (e.g. communication barriers, lack of privacy in the clinic), logistical difficulties (e.g. testing center is too far, results take too long), and cost of testing and therapy. Note that the sum of response percentages exceeds 100% because respondents were allowed to provide multiple reasons.

Population weighting by profession did not affect relative order of reasons provided. Population weighing by age was not performed because difference in mean ages between the sample and surveyed population was 3.3446 years, which is relatively small.

Table 4 shows which factors were significant predictors for reasons for not offering HIV testing. The first column lists reasons and factors (age or professional category) found to be significantly correlated. P-values and fitted coefficients corresponding to each factor are given.

DISCUSSION:

The most common reasons clinicians in Malawi give for not offering HIV testing to their patients are that they are not adequately trained in HIV counseling (50.29%); perception that the patient is not ready to be tested (49.52%); there is no indication for testing (35.56%); testing facilities are unavailable (35.37%); and that there is insufficient time available for testing (28.87%). Other reasons (patient personally known, non-conducive circumstances first encounter with patient, poor prognosis, lack of ARV, guardian present, logistical difficulties, patient age, not involved in clinical care, cost of testing of therapy, and forgot to ask) were given by less than 20% of clinicians.

Amongst these five most common reasons, only inadequate training in HIV counseling and testing, patient not ready to be tested and lack of testing facility were given significantly more often by members of particular clinician subgroups. Specifically, medical assistants were more likely to give the reasons not trained in HIV counseling (1.2693 ± 0.2290, _ +/- standard error) and patient not ready to be tested (-0.5380 ± 0.2169); general practitioners were more likely to give the reasons no testing facility (-08828 ± 0.3357) and patient not ready to be tested (0.6891 ± 0.3089); and those who indicated other profession were more likely to give the reason lack of testing facility (-1.04771± 0.5246). Thus, common reasons clinicians might not offer HIV testing to patients differ slightly amongst professional groups. The strongest correlation was shown between medical assistants, who constitute 46.33% of Malawi’s clinicians, and giving the reason not trained in HIV counseling, the most common reason given by the all clinicians (p=1.1200 x 108, _ = 1.2693 ± 0.2290).

Age is also significantly correlated with two of the five most common reasons for not offering HIV testing to patients (Patient not ready to be tested, No time for testing). However, the magnitude of the correlation of age with these reasons is small (0.02237 ± 0.007348 and –0.02736 ± 0.008384 respectively). Contribution of age to the odds ratio is within the range 0.5330 (_ = -0.02736, age =23) to 0.1121 (_ = -0.02736, age = 80). In contrast, the contribution of medical assistant to the odds ratio for the reason not trained in HIV counseling is 3.5584 (_ = 1.2693). Thus, common reasons clinicians might not offer HIV testing to patients are fairly homogenous across age groups.

Given that common reasons fro not offering HIV testing to patients differ slightly amongst clinician groups, programs may need to develop profession-specific interventions. It might be most practical to develop one collective intervention for all clinicians in Malawi, rather than different interventions for different clinician groups, and design and additional subcomponent to educate medical assistants on HIV counseling.

Although the reason lack of testing facilities was significantly correlated with profession, clinician interventions will not increase accessibility of facilities. Thus no profession specific program is necessary for this topic. However, all clinicians should be made aware of available testing venues. Use of a common program would simplify the development process and facilitate efficient use of resources.

While interventions to improve testing rates must target the most common reasons for not offering HIV tests to patients, more detailed information on these reasons is necessary. For example, since 50.29% of clinicians report that they are not adequately trained in counseling, further education is needed in this area. Thus areas in which clinicians feel their training is inadequate must be identified in order to improve education.