COMPLIANCE TO POSITIVE HEALTH , DIGNITY AND PREVENTION SERVICES AMONG HIV INFECTED INDEX PARTNERS IN HIV SERO-DISCORDANT RELATIONSHIPS IN NAIROBI COUNTY , KENYA

The undertaken study evaluated compliance to Positive Health, Dignity and Prevention (PHDP) practice among index partners in HIV sero-discordant relationship in Nairobi County, Kenya. PHDP involves a set of interventions that helps people living with HIV lead a complete and healthy life besides reducing the risk of transmission of the virus to others. These interventions were adopted in Kenya in 2013 by the National AIDS and STI Control Program (NASCOP) and the United States Government (USG) affiliates that support HIV prevention programming by the Ministry of Health (MOH). The evaluation focused on demographic factors, knowledge, perception and challenges encountered while adopting PHDP practices among index client. A cross sectional descriptive study that utilized both quantitative and qualitative methods of data collection.370 index partners in sero discordant relationship were recruited from three clinics within Nairobi County. HIV infected clients in discordant relationships who were enrolled in the three clinics and had accessed services within the last 3 months were eligible for the study. The clinic's patient registry was used to contact sequentiaUy those who met the inclusion criteria. Standardized data collecting tools were administered. Data was cleaned and analyzed using SPSS version 22. The results showed that out of 370 respondents 19.7% were male. The mean age was 36.6 years and 40.1% had education level of primary school and below. The group exhibited high level of PHDP knowledge at 90.8% and above however, only 66.2% complied with PHDP practice. There was significant relationship between condom supply, condom demonstration and PHDP compliance at P values of 0.034 and 0.018 respectively. Further analysis showed those index partners who had no challenge in accessing condom demonstration and supply complied more to PHDP practice. Consistence condom use was at 53.4% and family planning uptake was at 83.8%.Twenty eight percent had multiple sex partners while 27.3% consumed alcohol. Compliance to PHDP among index partners in sero-discordant relationship is not well adopted. This calls for the policy makers and health care workers to evaluate PHDP services in order to scale it up. However, PHDP is a very core HIV intervention .


I.1 Introduction
This chapter provides the background of HIV /AIDS and Positive health, Dignity and Prevention. It outlines the problem statement of the study, justifications, research questions and objectives, significance of the study and its limitations. Aconceptual framework is also provided

Background
Positive health, dignity, and prevention (PHDP) is an evidence based intervention that helps people living with HIV lead a complete and healthy life and reduce the risk of transmission of the virus to others especially those in HIV sero-discordance relationships. PHDP IS characterized by its systematic delivery of a range of combination, behavioral, and socio-cultural services within clinical and community settings ). The following interventions constitute the minimum package of services for PHDP in clinical setting; Condoms (and lubricant) and risk-reduction counseling, assessment of partner status and/or provision of partner testing or referral for partner testing, assessment for sexually transmitted infections (STTs) and provision of or referral for STr treatment (if indicated, and partner treatment if indicated), assessment of family planning needs and provision of contraception or safer pregnancy counseling or referral for family planning services and assessment of adherence and support or referral for adherence counseling (Remien, 2008) .  (KAIS, 2012). Forty four percent of these infections were due to heterosexual sex within a union or regular partnership. (Bankole, 1999) has shown that high rates of  transmission occur between RIV -discordant partners who are often in unstable relationships but unaware of both partner's HIV -1 sero-status due to poor testing rates and challenges with disclosure. 61% of all HIV infected married or cohabiting couples in Kenya are considered to be discordant, this corresponds to about 260,000 couples nationwide (KAIS, 2012) .. Nairobi, the capital city of Kenya and the study area has a HIV prevalence of 4.9 % which is slightly below the national prevalence rate.
Since the early 80's till recently, the understanding of HIV prevention as it relates to people living with HIV and in sero-discordance relationship has been inconsistent or illdefined. In addition, policies and programs aimed at people living with HN have been designed, for the most part, without the meaningful involvement of people living with RN (GNP+, 2009). PHDP is a relatively new area of focus for HN prevention programs. Historically, HIV prevention efforts focused on reducing HIV risk among indivi'duals assumed to be HlV-negative (Slayker, 2003). Program planners were . hesitant to target PLHIV with HN prevention interventions due to concerns about victim-blaming and increasing stigma for PLHIV. In addition, the limited availability of RIV testing services globally meant that most PLHN did not know their HN status.
Recently, however, antiretroviral therapy availability and associated care has been scaled-up dramatically worldwide. In addition, efforts to mainstream HIV care and combat stigma have also been scaled up as prevention strategies under PHDP (GNP+, UNAIDS, 2009 were also probed during the exercise to get accurate answers.

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The preparation of the study, its implementation, training of research assistants, stationary and data management and analysis was an expansive and an expensive venture. Hence, funding was an issue that was later solved through grant by the Canadian African Prevention Trials Network. This enabled us to recruit a larger study _ population to avoid selection bias. ' .

Introduction
This chapter reviews the literature on PHDP components which include HIVI AIDS in general and in sero-discordant relationships, sexually transmitted Infections and how they promote HIV transmission, anti-retro viral therapy and its role in prevention of

Antiretroviral Therapy
The introduction of antiretroviral therapy in 1996 and the public health approach to HIV treatment in resource-limited settings has changed the course of the epidemic (WHO, 2012). This has been illustrated by many observational studies that show antiretroviral therapy reduces sexual transmission of HIV in generalized epidemics (WHO, 2012). This is achieved through ART lowering HIV-I plasma ribonucleic acid (RNA), thereby reducing the infectiousness of PLHIV on treatment making it major prevention interventions especially in sero-discordant couples ). Sero-discordant couples' studies suggest that if the virus has been undetectable for six months, there is no risk of transmitting HIV. However, the infected partner must adhere to ART regimen and be free of STls (Garnett, 2008).
ART prevents morbidity, mortality, and transmission of HIV and tuberculosis as shown by the overwhelming success of the HIV Prevention Trials Network (HPTN) 052 study, which found that immediate highly active antiretroviral therapy (HA ART) reduced transmission to sero--negative partners by 96 % (NIH, 2011).Therefore, encouraging, HIV -positive people in sero-discordance relationship to consider initiating ART as a way to achieve an undetectable viral load is an importan new breakthrough for PHDP. Little attention has been paid to the contraceptive needs of sero-discordant couples. A focus on sero-discordant couples is warranted as these couples are faced with dual burdens of high risk of RIV transmission and risk of pregnancy, and resultant risk of mother to child transmission of RIV. (Sarkar, 2008). The challenge is to provide serodiscordant couples with family planning services that can allow them to effectively manage both their risks of HIV transmission and their fertility desires.

Positive Health, Dignity and Prevention (PHDP)
in the early years of the HIV epidemic, HIV testing and counseling was not widely • available in low-and middle-income countries. Consequently, few people living with RIV (PLRIV) were aware of their RIV status. RIV prevention programs, therefore, relied on messages for the general population that implicitly assumed that all individuals were in the same situation, i.e., uninfected or untested. Program planners were also hesitant to target prevention messages toward PLHIV due to fear of blaming the HIV-infected individual and adding to their already heavy burden of stigma (Auerbach, 2004). In light of recent studies showing the importance of HI V treatment in the prevention of ongoing transmission, these activities are increasingly focusing on .
individuals who know they are HIV-infected (Janssen & Valdiserri, 2004). This strategy was originally known as positive prevention, although it has also been called prevention " .

Introduction
This chapter describes the materials and methods that were used to carry out the study.
The study design, variables, study location, study population and sampling technique are described in details. Sample size determination, research instruments, pre-testing, reliability and validity are also covered. The section also addresses data collection techniques, data analysis and ethics considerations.

Research Design
This was a cross-sectional descriptive study that utilized both quantitative and qualitative approaches of data collection.

Independent variable
The independent variables were knowledge, perceptions, challenges and practice

Study Population
All index partners who had actively participated in PHDP activities in the previous three months as per the clinic registry, 18 years and above and agreed to participate in the study when contacted by the clinic team were eligible for the interviews 3.5.1 Inclusion criteria HIV positive client, in confirmed sero-discordant relationship, attending HIV care and treatment within the three selected study health facilities in Nairobi County. All eligible participants gave informed consent to participate

Exclusion criteria
Those who were challenged mentally and not able to make an informed decision Index partners in sero discordant relationships but not active in RIV care Indexpartners in sero discordant relationship that did not consent 3.6 Sampling Techniques Simple random sampling was carried out for selecting study sites from the NASCOP CCC registers for sites with discordant couples. Three clinics were picked and a register of all eligible index partners made. Systematic sampling was used to get study participants from the clinic registries. After calculating the Kth every 2nd index partner was enrolled into the study in Pumwani clinic, Majengo and Baba Dogo clinics.
Purposive sampling was used to select focus group discussions participants where each group comprised of ten participants. Those who participated in the face to face interviews were not invited to participate in the focus group discussions. A focus group discussion guide was used to elicit the required group dynamics and responses 3.7 Sample Size Determination (Fisher's et, al, 1998)

Pre-Testing
The study tools were pretested among ten HIV clients in confirmed sero discordant relationship in Pumwani clinic. Those who participated in the pre testing were not included in the study. appropriate corrections were then made on the questionnaires.

Validity
The validity was ensured by correct large sample size selection through systematic sampling. Careful planning, random selection of participants and the use of both qualitative and quantitative methods also enhanced the validity of the study.

Reliability
Reliability of the study tool was ensured through pre testing and appropriate corrections made to the items in the questionnaire.

Data Collection Techniques
Semi structured questionnaires were administered by trained research assistants.
Focused group discussions were audio-recorded and fully transcribed. After completion of the data collection, the data was cleaned before being exported to SPSS for analysis.

Data Analysis
Data analysis was done using SPSS version 22.0. The alpha level was set at 0.05.  interventions include adherence to clinic service, status disclosure, partner testing, STI screening and treatment, Condom demonstration and supply, family planning counseling and risk reduction. The above scores were interpreted as follows; Score 0; The number that accessed adherence only 0.8%, score 1; the number that accessed adherence and any other one intervention 11.4%; score 2; the number that accessed adherence and any other three intervention who met the minimum package of compliance 66.5%, score 4; the umber that received three interventions but did not • access adherence 3.8%, score 5; the number that accessed four interventions but did not accessadherence 2.2%, score 6; the number that accessed five interventions but did not accessadherence 0.3 %. ( Table 2) (Table 3).  •. The data showed that 66% respondents who had knowledge on importance of partner's testing complied to PHDP practice while 80% of those without knowledge also complied to PHDP practices as well. As per fisher exact test and p value of knowledge and compliance there is a significant relationship between knowledge on contraceptive •. use and compliance to PHDP practice among the index partners in sero-discordant relationship with p value of 0.017. (Table 6)  In bivariate analysis involving contraceptive knowledge and compliance to PHDP practice the odds ratio was 0.12 with a P value of 0.017. This shows that the respondents without contraceptive knowledge complied more to PHDP practice than those with contraceptive knowledge.   Couple HIV testing and counseling was reported to be an 'effective intervention to reach discordant couples as it will allow all the issues that involve the couple addressed at once. In addition it will give a discordant couple advice on how to live in their state .
. •. The focused group discussions show that male partner influence was reported by the study respondents to influence the adoption of some of the PHDP interventions including condom use and family planning. Thirty three percent of respondents reported that male partners may have a problem with contraceptive uptake because of the perception that it affects libido. Religion and side effects associated with some of the FP methods were also noted to influence FP; 53% of the study respondents reported that uptake of condom use among discordant couples is affected by many challenges; these include perception of lack of trust. In addition condom use may be affected by cultural norms that give men more power and a lack of understanding on the importance of condom. Seventy two percent of respondents reported that lack of education among men affects condom use as those at risk have low perceived risk. In addition, 67 % of inde~. partners reported that HN discordant men may find it more difficult to use condoms because of the perception that condom use indicates unfaithfulness. Four percent of respondents reported that men do not use condoms as they find them • uncomfortable. Polygamy was also cited by72% of index partners as a challenge affecting adoption of PHDP interventions. This is especially a challenge when one of the partners is HIV infected and the others are not infected. Long distance between the partners that necessitates one to sleep away for longer periods was noted to influence the relationship status of a discordant couple by increasing the risk of multiple partner relationships or casual sex. This was noted to influence both men and women 4.7.1 Challenges faced with index partners in compliance to PHDP Bivariate analysis of challenges showed that there significance relationship between condom demonstration and PHDP compliance with P value of 0.018. There is also a significant relationship between condom supply and compliance to PHDP practice with P value of 0.034 The results of condom supply and demonstration that showed significant association between them and compliance to PHDP practice were further analyzed through bivariate analysis for odds ratio as illustrated below.

Complied to PHOP
A cross tabulation table showed significant relationship between challenges faced by respondents and compliance to PHDP practice. Those respondents who accessed condom demonstration complied with PHDP practice two times more than those who did not access condom demonstration. Also those respondents who accessed condom supply complied with PHDP practice five times more than those who did not access condom supply. state. There was a significance relationship between knowledge on contraceptive use in HIV positive individual and compliance with PHDP practice at P value 0.017. Further data analysis showed that the respondents without contraceptive knowledge complied to PHDP intervention slightly more than those with the knowledge at an odds ratio of " 0.12.However, compliance to PHDP practice in both groups that had or had no knowledge on contraception use in HIV positive individuals was high . This finding also agrees with findings in (KHDS, 2009) that states the practice of family planning in Kenya has increased steadily since the early 1980s. The focus group discussion showed that there was adequate knowledge among the respondents on the importance of each of the PHDP interventions. The respondents also understood that pregnancy lowers one's immunity level to opportunistic infection and as a result they knew why family planning is important in HIV positive individuals. This is also confirmed by the low rate of pregnancies in all the three HIV sero-discordant cohorts that participated in the study. Seventy two percent perceived disclosure of one's status as necessary and doable, this is  in HIV sero-discordant couples where disclosure remains low, some participants found it impossible to disclose their RIV status to their sex partners and they expressed abandonment, stigma and violence as a hindrance to disclosure. This is also outlined in HIV sero discordant couples study that was done by (Benard, 2009), it showed serodiscordant couples desire intimate contacts and children born to them despite one of the partners being RIV sero-positive, and this led to fear of disclosure citing abandonment or violence by the RIV positive partner.
On alcohol consumption the respondents illustrated a good understanding between alcohol consumption and RIV/ ART, issues that were reported include said: alcohol consumption might make one forget to take their treatment completely or on scheduled time leading to ART resistance and poor immunity, less than a quarter of the study participants said they might forget to adhere to the clinic appointments hence miss care and treatment, while some said alcohol consumption will interfere with ART uptake and resulfinto ART failure leading to low immunity with high chances of opportunistic infections .This results agrees with the study done by National Institute of on Alcohol Abuse and Alcoholism (NIAAA, 2011) that alcohol consumption affects one's judgment hence diming perception risk of behavior that may lead to RIV transmission.
In focus group discussion most of the study participants had a positive perception of positive health, dignity and prevention interventions.
Interventions reported by the respondents included proper use of condoms, STI testing, ARV adherence, regular visits to the health facility, couple HIV testing and counseling and RIV testing for the discordant partner. Couple RIV testing and counseling was reported to be an effective intervention to reach discordant couples as it will allow all the issues that involve the couple addressed at once. In addition it gives discordant couples advice on how to live in their state.
5.1.5. Challenges faced by index partners in HIV sero-discordant relationship and how they affect PHDP compliance Most of the study participants found PHDP intervention, affordable, available, appropriate and acceptable and very important for their well being. Bivariate analysis of challenges showed that there was significance relationship between condom demonstration and PHDP compliance as well as significant relationship between condom supply and compliance to PHDP .The odds ratio the respondents who accessed both condom demonstration and supply complied more to PHDP practices compared to those who did not access either supply or condom demonstration. This agrees with (Slaylnaker, 2011) study that showed the importance of consistence condom use and HIV infection among discordant couples. The information from focused group discussions showed that male partners have a big influence on the adoption of most of the PHDP interventions including condom use and family planning, this finding agrees with three different studies (Sarkar N, 2008;Ngure G, 2012;and Faton A, 2009) who showed that male gender was reported to control the decision to use condom in serodiscordant relationships. Some respondents emphasized on this point from their report that some male partners may have a problem with contraceptive uptake because of the perception that it affects libido.

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Condom Use was also a challenge due to perception of lack of trust between the couple using condom, lack of knowledge on condom use among men and the loss of the real feeling of sex as well as discomfort in using condom, this is supported by a study done by (Steen, 20 I I) that states sero-discordant couples have low rates of condom use and ., may continue to have unprotected intercourse despite knowledge of their sero-status.
Multiple Partnerships were also cited as a challenge affecting adoption of PHDP interventions, this agrees with findings of (MacKenzie C, 2007) that show than concurrent relationships contribute to spread of HIV. This is especially a challenge when one of the partners is RIV infected and the others are not, this is supported by a study done by (All en, 2003) that illustrates that RIV negative individuals living in stable HIV discordant partners are twice as likely to get infected with HIV than those living in RIV negative concordant relationship. Distance between the partners was also noted to influence the relationship status of a discordant couple by increasing the risk of multiple partner relationships or casual sex resulting into acquiring HIV, this is supported by a study done by (Curie, 2005) that stated the direction of the spread of HIV was not only from returning migrants to their partners but also from women who stayed at home to their migrant partners.   •.

Conclusion
There are no physical risks associated with this study but you may feel uncomfortable if asked-, some questions which you may consider sensitive and invasive. You don't have to answer any question you are not comfortable with.

Benefits
The information you provide to the investigator will shed light on the factors that contribute to adherence to PRDP intervention among index clients in sero-discordant relationships, and this will assist us in informing other discordant couples and also help the government to develop suitable programs for RN discordant couples in the country.

Other Information
Any information given to the study will be kept private. Your name will not be used in any report coming from this study. The questionnaires and the consent form will be safely kept where only the study staff may have access to the information. Hallo. My name is Maureen Akolo. I am a master student at the Kenyatta University, community health department. I am conducting a study to find out if index clients in HTV sero-discordant relationships have PHDP knowledge, their perception on this intervention, their current practices and challenges encountered. I would like to invite you to participate in this study. The study aims to gather this information and help address issues affecting PHDP. We are looking forward to hearing your experiences and learn from you and your peers. We are carrying out focus group discussions to gather this information. We are asking if you will be willing to participate in one of these group discussions and share your views. Focus discussion groups have about 8-12 people who get together and discuss their ideas and thoughts about important issues. share what others have told you. We will not use any names when writing our reports.
We would like to invite you to participate in one of the planned focus group discussion this week. This session will be tape-recorded and a transcript of the discussion will be made. By consenting to participate in the study, you are agreeing to the tape recording of the session. The session will take about 2 hours to complete.
If you agree to take part in the study, you will be given a soda during the session and provided with 100 Shillings to help pay for your transportation fee to your Nairobi home You may not feel comfortable answering some questions in front of your peers. You have the right to refuse to answer any question that you do not wish to answer. Also, you can choose to leave the discussion at any time. You do not have to participate if you do not want to but this will not affect your chances of ever joining or using the services provided through the program.
The benefit to you is that you will be sharing your opinions and experiences that will help improve the service provided to you especially those related to uptake of the antiretroviral treatment.
By agreeing to participate you are agreeing not to share information provided by this group outside this. focus g oup discussion. However, we cannot guarantee that information discussed in the group will not be shared, so please consider this before discussing personal matters. We will protect information about you and your taking part in this research to the best of our ability. Your name will not appear on the interview records or transcripts. We will keep all sensitive files, notes, and interview tapes password protected or in locked cabinets and we will destroy all interview tapes at the end of the study. If the results of the research are published, neither your name nor personal identifying characteristics or those of anyone else in the study groups will be revealed.
• Do you have any questions?
• Do you agree to participate in the focus group discussion? If you do not want to participate, you may leave the room at this time.

FOCUS GROUP FACILITATOR:
You must sign below before proceeding. Your signature certifies that the objectives and procedures of this study have been read to the focus group participants. It also certifies that you have answered all the questions that the respondents had about the study and that each participant remaining in the room has voluntarily agreed to take part in the research .
•. • The first step is to explain to participants that this focus group discussion will be recorded. Explain why you need to record the session and give them time to express questions or concerns.
the informed consent process.
• As a warm up, you as the moderator need to introduce yourself (a bit of information about your job, your family, and what participants can call you) and give some information about the number of discordant couples and the PHDP services being offered as per the CDC outline • The discussion will assess the couples knowledge, awareness and attitudes· to the HIV/AIDS disease and PHDP intervention. The facilitator will assess the general information about PHDP services, especially status disclosure and partner testing ilIml"~J'~nrv-(, RA . • ..
Thank you for participating THE END