ABSTRACT
South Africa implemented Universal Test & Treat (UTT) guidelines in September 2016. We examine HIV/ART knowledge among newly diagnosed from a prospective study enrolling newly diagnosed HIV-positive adults, under same-day ART policy, at four primary health clinics in Johannesburg, South Africa. We describe factors associated with high HIV/ART related knowledge score among newly diagnosed patients using Poisson regression. We included 652 HIV positive adults (64.1% female; median age 33 years (IQR: 28–39). Overall, 539 (82.7%) patients were classified as having high HIV/ART knowledge, 14.7% medium knowledge and 2.6% had low knowledge. HIV/ART knowledge was mainly associated to high English literacy (aRR 0.9 Medium vs High, 95% CI: 0.8–0.9; aRR 0.7 for Low vs High: 95% CI: 0.6–0.9). However, patients who did not disclose their intentions for HIV test (aRR 0.9, not disclosed intentions vs having disclosed intentions to test, 95% CI: 0.8–0.9), participants who indicated concerns with ART (aRR 0.9 moderate to high vs low concerns, 95% CI: 0.8–0.9) were less likely to have high knowledge. Our results highlight a correlation between English literacy and good knowledge. There is a need to make information more accessible in a non-English language. Addressing this gap is critical in achieving the WHO targets.
Introduction
South Africa recently adopted the World Health Organisation (WHO) guidelines for universal and same-day initiation (SDI) of antiretroviral therapy (ART) for all HIV diagnosed individuals and has greatly expanded access to ART (Motsoaledi, Citation2014; NDoH, Citation2016, Citation2017; UNAIDS, Citation2014). Yet adherence to ART and long-term retention of patients in HIV care remain challenging (Onoya et al., 2021).
A lack of knowledge about HIV and ART influences adherence to ART, leading to the incorrect use of drugs (Goujard et al., Citation2003; Langebeek et al., Citation2014; Nozaki et al., Citation2013; Ramadhani et al., Citation2016). A recent national survey reported a decline in the knowledge of HIV transmission and prevention between 2008 and 2012, with only 26.8% of South Africans reported to have accurate knowledge (Shisana et al., Citation2014).
Comprehensive HIV knowledge is even more pertinent in the era of the SDI policy because ART initiation and retention targets are higher (UNAIDS, Citation2014). This study aimed to determine HIV and ART related knowledge among persons diagnosed with HIV under the SDI policy in Johannesburg, South Africa. Additionally, we aimed to explore the determinants of high HIV and ART knowledge in this population.
Methods
The enrolment of patients was conducted according to previously described criteria (Onoya et al., Citation2021). Our study population included participants with a median age of 33 years (IQR: 28.0–39.0), 64.1% were female and 35.3% were married.
Variable definitions
We used a fifteen-item index (), previously used in the 2012 South African National HIV, Behaviour and Health Survey, to collect HIV and ART knowledge (Shisana O & Onoya D et al. (2014) South African National HIV Prevalence, (2014)). Questions on HIV included transmission pathways, prevention methods, myths about HIV positive people and questions about HIV status disclosure. Questions on ART knowledge included, how ART controls HIV progression, implications of non-adherence and questions about side-effects. For the final analysis, we dichotomised the final outcome knowledge score into low/medium vs high knowledge score.
Table 1. Characteristics of sample population by their level of education (n = 652).
Other socio-demographic factors assessed included age, sex, highest education completed, marital status, employment status, whether the patient was the household breadwinner.
The study protocol was reviewed and approved by the Human Research Ethics Committee of the University of Witwatersrand (M1704122). All personal identifiers were removed from the final analytic dataset.
Statistical analysis
We describe characteristics of study participants using proportions, frequencies, means with standard deviation (SD), and medians with interquartile ranges (IQRs) as appropriate. Factors associated with having a high HIV/ART knowledge was assessed using log-binomial regression modelling (Zou, Citation2004), reporting adjusted risk ratios (aRRs) with 95% confidence intervals (CIs). Additionally, we assessed the characteristics of patients with a high English Literacy score using log-binomial regression. Data analysis was conducted using STATA version 14 (StataCorp, College Station, TX).
Results
Characteristics of newly diagnosed with HIV patients by their level of education
A total of 652 newly HIV diagnosed participants were enrolled (), with 51.5% who spoke Nguni languages (which include: Zulu, Xhosa, Ndebele, Swati, etc.). Females (58.9%) reported a higher English literacy compared to males (47.1%). English literacy was highest among participants who had ≥ grade 12 level of education (90.3%), followed by participants with a secondary level of education (49.7%). The majority (62.8%) reported a paying job or business as their primary source of income. Overall, 51.4% indicated not having an active sexual partner in the prior year, while 6.0% indicated having two to four sexual partners in the same time period ( and ).
Table 2. Demographic and clinical factors associated with having a high score of HIV/ART knowledge among newly diagnosed patients.
Table 3. Demographic and clinical factors associated with having a high English literacy among newly diagnosed patients.
Social support and health-seeking behaviour at HIV diagnosis
Overall, 53.0% had visited a clinic, and 31.6% had also tested for HIV in the prior 12-months. Perceived social support was high (95.3%), but only 62.4% had disclosed their intention to test for HIV. Similarly, 96.3% of participants intended to disclose their HIV positive status. Overall, 52.1% of participants expressed moderate concerns about ART, with 47.7% expressing low concern.
Factors associated with having a high score of HIV and ART knowledge among newly diagnosed patients
After adjusting, high HIV/ART knowledge was associated with high English literacy (aRR = 0.9 for Medium vs High, 95% CI: 0.8–0.9; aRR = 0.7 for Low vs High: 95% CI: 0.6–0.9). Similarly, participants who did not disclose their intention to test for HIV (aRR = 0.9 for non-disclosure vs having disclosed intentions to test, 95% CI: 0.8–0.9), participants with ART concerns (aRR 0.9 for moderate to high vs low concerns, 95% CI: 0.8–0.9) also had low HIV and ART knowledge.
Factors associated with having high English literacy among newly diagnosed patients
After adjusting, a higher level of education (aRR = 10.8 for secondary vs primary school 95% CI: 2.7–43.2; aRR 22.6 ≥grade 12vs primary school: 95% CI: 5.6–90.6) and partipant’s source of income being from parents, relatives or friends (aRR = 2.5 for parents/relatives/friends vs paid job/salary/business: 95% CI: 1.9–3.4) were important predictors of high English literacy.
Discussion
This study aimed to determine factors associated with having a high knowledge of HIV and ART immediately after HIV diagnosis and post-test counselling in Johannesburg, South Africa. Overall (82.7%), the level of post-test HIV/ART knowledge is higher than proportions previously reported in population-level cross-sectional surveys in South Africa (Evans et al., Citation2018; Terblanche & Stellenberg, Citation2014). These results are similar to findings from clinic-based HIV positive populations in other settings (Olowookere et al., Citation2012; Raberahona et al., Citation2019). However, despite the high knowledge, at least 17.3% of the participants had low to medium knowledge, which causes concern as study participants were interviewed immediately post- HIV test counselling.
Counselling is important in the SDI policy era to ensure high levels of ART initiation and sustained engagement in HIV care (Ford et al., Citation2018; Nhassengo et al., Citation2018; Plazy et al., Citation2017). Studies conducted among lay counsellors working in primary health facilities in South Africa have highlighted the lack of knowledge among counsellors. (Lewin et al., Citation2005; Mokhele et al., 2020; Mwisongo et al., Citation2015; Peltzer & Davids, Citation2011). This knowledge gap makes it difficult for counsellors to identify gaps in patient knowledge and address misconceptions regarding HIV and ART. Other studies (Dyrehave et al., Citation2016; Nachega et al., Citation2012; K. Peltzer et al., Citation2012; Waite et al., Citation2008) have shown that both low literacy and a lack of information from health providers are associated with low treatment adherence, rather than low literacy alone. HIV counsellors are often the first to interact with patients, and therefore need to take up the role of supportive-educators. This is necessary to equip HIV patients with the knowledge needed to support their decisions on when and how to engage with HIV care.
We also found that patients who were concerned about taking ART had lower HIV/ART knowledge, particulary those who were over 30 years old. Barriers to ART adherence have been well documented including the intitation and later discontinuation of treatment (Kagee & Delport, Citation2010). Given the importance of adherence to the success of lifelong ART, it is essential to address patient concerns about ART and equip them with the necessary knowledge. We also found that participants whose source of income was their parents were more likely to high levels of education and this is similar to previous studies (Baliyan et al., Citation2012; Botha, Citation2010; Hofmeyr, Citation2020).
Furthermore, good knowledge was associated with high English literacy, suggesting that the English language remains the main language used in health education communication and materials in primary health facilities (Griffin et al., Citation2006; Haridas et al., Citation2014; Janse van Rensburg, Citation2020). This is particularly concerning as South Africa is a linguistically diverse country with 11 official languages. Additionally, English is not widely spoken across the country, especially in rural areas and among rural migrants in urban settings. This suggests that patients may not fully comprehend the information being given to them. Therefore, there is a need to ensure that health education communication that caters to patients who do not understand English.
Study limitations
The results of this study should be considered in light of study limitations. Firstly, we only surveyed HIV positive patients that had engaged in healthcare services, it is possible that some HIV positive people with low knowledge would have completely avoided testing and this could explain the inability to observe some of the previously reported factors. Secondly, we interviewed patients immediately after their post-test counselling and this may explain the overall high HIV/ART knowledge; the levels of knowledge are not truly representative of the general population.
Conclusions
Our results highlight a strong correlation between English literacy and high HIV and ART knowledge. However, there is a need to make information more accessible in non-English language, particularly among patients with limited English proficiency. HIV programmes need to be more focused on improving HIV and ART knowledge through health promotion and improving the quality of counselling, and using health care visits as an opportunity to provide basic education to patients. Specifically, this study shows a need to equip lay counsellors with standardised counselling training and address the capacity and structural challenges at the sites. Addressing this gap is critical in achieving the WHO targets.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
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