SEXUAL BEHAVIOUR AS A CORRELATE OF VOLUNTARY COUNSELING AND TESTING UTILIZATION FOR HIV/AIDS AMONG STUDENTS OF PORT-HARCOURT POLYTECHNIC, RIVERS STATE, NIGERIA

ABSTRACT
The prevalence rate of HIV infection has been onthe increase in Nigeria and half of all new infectionsoccur among adolescent between the ages of 15-24 years old, who mostly are in tertiary institution. Voluntary Counseling and Testing is a strategy towards prevention and control of HIV. Despite findings high level of awareness of the availability of VCT by adolescents and of willingness to utilize VCT, utilization of this service is still low. In light of this, the study aimed at assessing the relationship between sexual behaviour and utilization of VCT.
This research was a cross-sectional survey which was carried out among 357students of the Port-Harcourt Polytechnic, Rivers state, Nigeria. A semi-structured instrument (questionnaire) was used for data collection. Data collected were analyzed using Statistical Package for Social Science (SPSS) version 21 with levels of significance set at 0.05.
There were 125 males (35%) and 212 females (59.4%) respondents with a mean age of 16.96 ± 9.145. It was found that respondents’ attitudinal disposition was below average (49.44%), this was however determined to predict willingness of respondents to undergo VCT [df = 1; R2 = 0.024; P < 0.05]. The result revealed that despite willingness to undergo VCT by respondents was high (81%) only 42% of the respondents voluntarily got tested for HIV. Sexual behaviour of respondents was good (55.7%) however, data showed that only 43% of respondents used condoms during sexual intercourse and also 62% practice sexual relation with multiple partners. Major finding of the study found that sexual behaviour of respondents had a 7.8% influence on their utilization of VCT [df = 1; R2 = 0.078; P < 0.05]. Further findings indicated that opinions of respondents significant others, family and close friends in encouraging them to undergo VCT had an influence of 6.2% on utilization of VCT [df = 1; R2 = 0.062; P < 0.05] likewise was their control beliefs, which had a 1.7% influence on their utilization of VCT [df = 1;R2 = 0.017; P < 0.05].

This study concluded that adolescents’ sexual behaviour plays a pivotal role in determining utilization of VCT among adolescents. This is inferred that adolescents who are not sexually active despite having a high willingness to undergo VCT may not see it deem fit to undergo VCT as such individual doesn’t feel susceptible to infection of HIV, sexually active individuals however are likely to undergo VCT with the perception of increased susceptibility to infection. It was recommended that health intervention be aimed at improving healthy sexual behaviour among students and also focused should be placed on sexually active students on the importance of regularly seeking VCT. The findings of this study will improve health promotion in identifying an important factor to improving utilization of VCT.

CHAPTER ONE
INTRODUCTION
1.1       Background to the Study
Since the Human Immunodeficiency Virus (HIV) was first discovered three decades ago, it is estimated that globally approximately 1.8 million adults and children had died of Acquired Immune Deficiency Syndrome (AIDS)-related illnesses by the end of 2010 (UNAIDS, 2010). In the same year 2010, it was estimated that there were 34 million people living with HIV globally, with the bulk, 22.9 million, residing in Sub-Saharan Africa. Globally, adolescents bear the brunt of the epidemic as they account for one third of currently HIV and AIDS infected individuals and half of new infections of HIV globally (Dehne & Riedner, 2005; UNAIDS, 2011).
According to the United Nations Joint Programme on HIV and AIDS (UNAIDS), 2.1 million people were newly infected with HIV in 2013, and an estimated 35 million people were living with the virus (UNAIDS, 2015; Wilson, Wright, Safrit & Ruby, 2011). It has since been dubbed as one of the greatest humanitarian and development challenges facing the global community in recent times (Adekeye, 2010). Globally, there is an estimated 1.2 billion adolescents, constituting 18% of the world’s population (UNICEF, 2012). Available evidence shows that about 2.2 million of these (60% of them, females) are living with HIV, and many are unaware of their infection (WHO, 2016).
The first case of AIDS was reported in Nigeria in 1986 in a sexually active 13-year-old girl as recorded by the Federal ministry of Health and Human Services (1992). Since this first report, the prevalence rate of HIV infection has been on the increase in Nigeria; from 1.9% in 1993 to 5.8% in 2001 and with a decline to 4.6% in 2010 (NACA, 2011). In adolescents, 15-24 years rates declined from 6.0% in 2001 to 4.1% in 2010. One third of currently infected individuals are adolescents aged 15 to 24 years, and half of all new infections occur in this same age (Dehne & Riedner, 2005). It was also estimated that Nigeria accounted for the highest AIDS-related deaths in Sub-Saharan African (Global Burden of Disease: Nigeria, 2010; UNAIDS, 2013).
One reason for high prevalence rates is that most people are unaware of their HIV status, Sekatawa (2000) revealed that75% - 80% of new infections came about as a result of unprotected sexual contact with an infected person, attributable to the low level of HIV testing among adolescents (Idele, Gillespie, Porth, Suzuki, Mahy, Kasadde et al., 2014; John, Okolo & Isichei, 2014; UNAIDS, 2013). It was estimated that less than 40% of the people in Sub-Sahara Africa know their HIV status despite the fact that the present HIV intervention packages depend on the knowledge of individual’s HIV status (Mbamara, Obiechina & Akabuike, 2013).
The rate of HIV and AIDS increase is very alarming amongst adolescents who are  found within  the age brackets of 15 and 24 years especially among students of higher institutions of learning who do not have knowledge of their HIV status (Kennedy & Ibinabo, 2013; Schantz, 2012). Risky sexual behavior and alcohol consumption has been regarded as the major health risk behavior engaged by adolescents that predisposes them to infection of HIV (Elkington, Bauermeister & Zimmerman, 2010; Nkansah-Amankra, Diedhiou, Agbanu, Harrod & Dhawan, 2011). Early initiation of sexual intercourse, sexual intercourse under the influence of alcohol, unprotected sexual intercourse and multiple sexual partners constitute sexual risky behavior exposing adolescents to several health problems especially HIV infection (Baltazar, Conopio, Moreno, Ulery  & Hopkins, 2013).
Knowing HIV status of individual has been established to be the entry point to other HIV services and an opportunity for individuals to learn not only their HIV status but correct knowledge and also gain accurate risk perceptions, thereby encouraging safer behavior, it helps the individual to make informed decision, assess personal risk for HIV and further develop risk reduction strategy (WHO, 2010) however, barriers to HIV Voluntary Counseling and Testing (VCT) has been revealed to include lack of awareness of available services, low perception of personal risk, fear of negative consequences associated with a positive test result (including stigma), concerns about confidentiality, financial burden of testing, and lack of HIV and AIDS knowledge and this has immensely contributed to willingness and utilization of VCT by adolescents (Idele, Gillespie, Porth, Suzuki, Mahy, Kasedde et al., 2014; Musheke, Ntalasha, Gari, Mckenzie, Bond, Martin-HIber et al., 2013; Oginni, Obianwu & Adebajo, 2014).
Studies have revealed considerable reduction in risky sexual behaviors after utilization of VCT (Arthur, Nduba, Forsythe, Mutemi, Odhiambo & Gilks, 2007; FHI, 2006; Kirakoya-Samadoulougou, Yaro, Deccache, Defer, Meda, Robert & Nagot, 2013; Sherr, Lopman, Kakowa, Dube, Chawira, Nyamukapa et al., 2007; Wusu & Okoukoni, 2011), as suggested by Jansen, Holtgrave, Valdiserri, Shepherd, Gayle and De (2001) that knowing individual’s HIV status can influence one to be more carefully and adapt HIV preventive behaviors, such as faithfulness or abstinence. Individuals with increased sexual behaviour perceived themselves at high risk of infection (Singh, Lall, Gupta, Bose & Singh, 2014) and according to Kitali, Mahande, Mosha, Kessy, Njau and Mushi (2013) it was gathered that most participants who utilized VCT were sexually active and practice multiple sexual partnership. However, it has not been established if an individual’s sexual behavior predicts their utilization of VCT.

1.2       Statement of the Problem
The National Department of Health (NDOH, 2010) guideline explained that adolescent is particularly at risk of HIV infection in comparison to the adults. Studies have shown that half of all new HIV infections are found more within adolescents aged between 15 and 24 years (Wusu & Okoukoni, 2011) and that approximately 50% of HIV related deaths reported among adolescents between year 2005 and 2012 were influenced by inadequate friendly VCT services, poor prioritization of adolescent issues, inadequate treatment and lack of support to the adolescents (Hopkins, 2012).
Africa’s young people aged 15–24 are disproportionately infected and affected by HIV/AIDS. Nearly 4 million (UNICEF, 2011) Sub-Saharan African youth currently live with the virus, and 20 countries in Sub-Saharan Africa accounted for about 69% (UNAIDS, 2011) of all new HIV infections globally among young people in 2009. HIV prevalence is more than twice as high among young girls (3.4%) than among their male counterparts (1.4%) (UNAIDS, 2009)Across the continent, HIV prevalence among young people varies considerably from less than 0.1% in Egypt (with its highly concentrated epidemic among injecting drug users [IDUs] and Men who have sex with men (MSM) (Parker, 2007) to more than 25% in Zimbabwe. Nigeria and South Africa have the highest number of adolescents living with HIV/AIDS, as many as 1.3 million in Nigeria and 1.9 million in South Africa (UNAIDS, 2009). African youth have suffered disproportionately from the effects of the epidemic. Millions have lost at least one parent to AIDS, eight out of ten individuals orphaned by AIDS live in Africa, and an estimated 55% of all AIDS orphans in the region are adolescents. (Biddlecom, 2007)
Over the  years, there have been unavailable VCT clinics  and especially in Nigeria, there were no record of any VCT centers as far back as 2005 (WHO, 2005), however, with the introduction of VCT clinics, Voluntary Counseling and Testing became crucial for HIV prevention and considered a priority intervention for the provision of comprehensive HIV and AIDS care, management, and treatment .The introduction, establishment,  and utilization of VCT services have since been reported to be low which might be as a result of adolescents feeling less susceptible to HIV infections and other factors that has been established to be associated with  the spread of HIV (Gatta & Thupayagale-Tshweneagae, 2012; Mwangi, Ngure, Thiga & Ngure, 2014).
Despite findings from studies revealing high level of awareness of the availability of VCT by adolescents and also the high level of willingness to utilize VCT, utilization of this service is still low in Nigeria  (Ikechebelu, Udigwe, Ikechebule & Imoh, 2006; Iliyasu Abubakar, Kabir & Aliyu, 2006; Onyeonoro, Emelumadu, Chuku, Kanu, Ebenebe, Onwukwe et al., 2014).With adolescents being at a stage of their greatest risk taking behavior, sexual risky behavior is prevalent among them, predisposing them to infection of HIV (Baltazar, Conopio, Moreno, Ulery & Hopkins, 2013. This has brought to light the need for an exploration of individual’s sexual behavior as a factor that influences the utilization of VCT which has been overlooked in recent studies.

1.3       Objective of the Study         
The main objective of the study is to assess sexual behavior as a correlates of VCT utilization for HIV among students of Port-Harcourt Polytechnic, in Rivers State, using the components of the Theory of Planned Behavior. The specific objectives are to:
  1. identify the sexual behavior pattern of respondents;
  2. determine the level of willingness of respondents to utilize VCT;
  3. assess the attitudinal disposition of respondents towards VCT for HIV;
  4. identify the effect of attitudinal disposition of respondents on their willingness to utilize VCT for HIV;
  5. assess the level sexual behaviour of respondents influences utilization of VCT by respondents and
  6. find the level of utilization of VCT by respondents.
1.4       Research Questions
  1. What is the sexual behavior pattern of respondents?
  2. At what level is the willingness of respondents to utilize VCT?
  3. To what extent is the attitudinal disposition of respondents to VCT for HIV?
  4. How does the attitudinal disposition of respondents affect their willingness to utilize VCT for HIV?
  5. At what level does sexual behaviour of respondents influence utilization of VCT by respondents?
  6. What is the level of utilization of VCT by respondents?
1.5       Hypotheses
Ho1:   There is significant difference in the sexual behavior of respondents across their demographic characteristics.
Ho2:   There is significant difference in the level of willingness of respondents to utilize VCT across demographic characteristics of respondents.
Ho3:   There is significant difference in the attitudinal disposition of respondents towards VCT across demographic characteristics of respondents.
Ho4:   There is significant association between attitudinal disposition of respondents and willingness to utilize VCT.
Ho5:   There is significant association between subjective norm of respondents and their willingness to utilize VCT.  
Ho6:   There is significant association between control beliefs of respondents and their willingness to utilize VCT
Ho7:   There is significant difference in the level of utilization of VCT across demographic characteristics of respondents.
Ho8:   There is significant relationship between respondents’ willingness and their behavior in practicing VCT.
Ho9:   There is significant association between respondents’ sexual behavior and utilization of VCT. 

1.6       Scope of the Study                                       
This study focused on the sexual behavior of students as a correlate of Voluntary Counseling and Testing Utilization for HIV and AIDS in Rivers-State; the researcher has limited the research to the students of Port Harcourt Polytechnic, Rumuola, Rivers state who falls between the ages of 15-24 years. This was done because the institution provides the researcher with the characteristics needed for the study in large number expected of the study.
A cross-sectional design was used in this study, where a total of 370 students participated in    this study.  Data was collected using a self-developed questionnaire which was administered randomly among students of the institution.

1.7       Justification for the Study
The importance of VCT in the prevention and control of HIV and AIDS infection cannot be overemphasized as it is an important strategy towards achieving the goal (Abebe & Mitikie, 2009; Sebudde & Nangendo, 2009). An increase in the level of utilization of VCT where adolescents can get tested and get ample information on HIV prevention will help the reduction in new infections of HIV among adolescents as they will be aware of their HIV status and inevitably engage in healthy behaviors and take steps towards prevention of transmission. Also the relatively high levels of sexual activity among adolescents demonstrate the need for educating young people regarding safer sexual practices. This young population should have access to Sexual Reproductive Health (SRH) services and youth-focused sexuality education that goes beyond abstinence-only messages. (Population council, 2014)
Studies have revealed a low level of utilization of VCT for HIV across the Sub-Saharan African (Gatta et al., 2012; Mwangi, et al., 2014; Okiriamu, Onyango, Odiwuor & Simatwa, 2013; Ramirez-Avila, Nixon, Noubary, Giddy, Losina, Walensky et al., 2012) this has been attributed to so many factors however, there is need to understand adolescents’ willingness to utilize VCT services using the Theory of Planned Behavior (TPB)  construct, exploring the interpersonal and intrapersonal factors influencing the behaviour.
This study aims at identifying the areas of adolescents component where focus need to be placed in improving the utilizations of VCT services by developing an intervention guided by the model employed from this study. This research will be of importance in improving health and quality of life of adolescents and overall reduce incidence rate of HIV in the country.

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