Consistent Condom Use and Associated Factors among HIV-Positive Clients on Antiretroviral Therapy in North West Ethiopian Health Center, 2016 GC

Background The burden of Human Immune Deficiency Virus or Acquired Immune Deficiency Syndrome is high in sub-Saharan countries including Ethiopia which have over two-thirds of the global HIV burden. Many would argue that consistent condom use is not most effective method for HIV prevention. Condoms offer protection against unwanted pregnancy and some sexually transmitted infections including Human Immune Deficiency Virus, when used correctly and consistently. Inconsistent use of condom by People Living with Human Immune Deficiency Virus or Acquired Immune Deficiency Syndrome on Antiretroviral Therapy will lead to further worsening the Human Immune Deficiency Virus infection epidemic and reinfection with new drug resistant viral strains. Objective To assess magnitude of consistent condom use and associated factors among HIV-positive clients on Antiretroviral Therapy in North West Ethiopian health center, 2016 GC. Method An institutional based cross-sectional study was conducted, from April 15 to June 10, 2016. A total of 358 patients on ART in Koladiba Health Center had participated in this research. Koladiba Health Center is the first health center in Ethiopia that is found in Debbie district, which is located in north Gondar Zone. Study participants were selected by simple random sampling technique. Data were collected by using pretested structured questionnaires and analyzed using SPSS version 22. Descriptive statistics was computed and binary and multiple logistic regressions were also conducted to examine the effect of selected independent variables on consistent condom use. Result A total of 358 ART clients participated in the study with response rate of 90%. Among study participants, 138 (38.5%) were in the age category of 35-44 years. About 216 (60.3%) of the participants were female and 325 (90.8%) were Orthodox followers. Consistent condom use was reported by 130 (55.8%) sexually active study subjects. Respondents in rural residence (AOR=0.326, 95% CI: 0.109, 0.973) and sexual partner initiated condom use (AOR=0.031, 95% CI: 0.005, 0.186) were found to be the independent predictors of consistent condom use. Conclusion and Recommendations Consistent condom utilization among HIV clients on ART was low (55.8%). Place of residence and condom use initiation during sexual contact were significantly associated with consistent condom use. It is better to give more emphasis on health education and counseling service about consistent condom use for PLWHA who are on ART during follow-up especially for those who came from rural areas.


Introduction
. The vast majority of people living with HIV are in low-and middle-income countries including Ethiopia [2].
Prevention methods, particularly consistent condom use, have helped to reduce HIV transmission and curtailed the broader spread of HIV in settings where the epidemic is concentrated in specific populations [3].
In Ethiopia the response to HIV/AIDS epidemic showed considerable progress and achieved encouraging results. However, the nature of epidemic and its fueling factors creates a complex challenge to the ability of health and other sectors to meet the target for HIV/AIDS prevention and control in the country [4].
Combination of HIV prevention is likely to be most effective when different points in the "transmission cycle" are impeded, combining strategies to reduce infectiousness of HIV-positive persons with strategies that reduce HIV susceptibility in the uninfected person. Most early HIV prevention policies focused heavily on HIV-negative, atrisk persons (e.g., using behavior change communication campaigns). However, seronegative persons represent a very large pool to target high coverage. Strategies to reduce the infectiousness of HIV-positive individuals by reducing secondary HIV transmission should be part of the prevention policy. Theoretically, if high proportions of people living with HIV/AIDS (PLHIV) learned their HIV serostatus and adopt interventions such as ART coupled with behavioral risk reduction, this could have a significant impact on HIV transmission [5].
Condom use is a critical component in a comprehensive and sustainable approach to the prevention of HIV and other sexually transmitted infections (STIs) and for preventing unintended pregnancies especially among people with HIVpositive clients. The maximum protective effect of condoms is achieved when their use is consistent rather than occasional [6]. Previously, the focus of HIV prevention efforts in most countries including Ethiopia was largely on people uninfected with HIV. Sexual risk practice of HIV infected persons did not receive due attention. Inconsistent use/nonuse of condom by PLWHA on ART will lead to further worsening the HIV infection epidemic and reinfection with new drug resistant viral strains. Therefore the aim of this study is to determine the level of consistent condom use and some associated factors among HIV-positive clients on antiviral therapy in KollaDiba Health Center.

Methods
. . Study Design and Period. Institution based crosssectional study was carried out from April 15 to June 10, 2016 GC.
. . Study Area. The study was conducted at KollaDiba Health Center that is found in Dembia district, which is located in north Gondar Zone, Amhara region, and it is found 729 km from Addis Ababa and 35 km from the ancient city of Gondar. Dembia is one of the districts of North Gondar Administrative Zone and is geographically flat land. The area covers 1270 km with a total population of about 263,000 and the population of the district is predominately Amhara, with Orthodox Christianity being the main religion. There are one health center, one government hospital, and two private clinics. Koladiba Health Center is the first health center in Ethiopia established in 1954 EC, in the regime of Emperor Haile Selassie in collaboration with WHO and USAID to control malaria epidemic, which occurred in Kolladiba town in Dembia district. Currently Koladiba Health Center provides outpatient treatment, family planning, maternal and child health service, and a wide variety of health services including ART, TB, and adolescent health service. In ART clinic 956 ART clients were registered and 566 clients were on followup currently and the rest of the clients were transferred out, died, and lost.
. . Source Population. The study populations are all people living with HIV/AIDS who are on ART in Koladiba Health Center.
. . Study Population. Study populations are PLWHA on ART who attended at the time of data collection in Kolladiba Health Center and those who fulfilled inclusion criteria.
(ii) ART attendees who have been on ART for at least 3 months.

. . Exclusion Criteria
(i) Those who are mentally ill.
(ii) Those who are unable to communicate verbally.
. . Sample Size Determination. The sample size was calculated by using single population formula where p-value was taken from a research done in Addis Ababa which is 63.1% consistent condom use, 95% level of confidence, and 5 % marginal error [7]. . . Data Collection Method. A well-structured pretested and interview based questionnaire was used to collect appropriate data from those who are on ART follow-up.

. . Data Quality and Clearance.
To ensure the quality of data, 10% of sample size of the questionnaires was pretested in Gondar University Hospital ART Clinic. In addition to this, the questionnaire was designed in English, translated to Amharic, and then back translated to English to verify content. The collected data was checked by investigators for completeness, accuracy, and consistency.
. . Data Processing and Analysis. After data collection, data were entered and analyzed using SPSS version 22. Descriptive statistics was computed and binary and multiple logistic regressions were also conducted to examine the effect of selected independent variables on consistent condom use.
. . Ethical Consideration. Ethical clearance was obtained from School of Nursing Ethical Review Committee (ERC), in University of Gondar before the research started. Respondents were informed about the objective and purpose of the study and a signed informed consent was obtained from each respondent. Moreover, all the study participants were informed that they have a full right to participate or decline participating in the study and all the study participants were assured of confidentiality. No identifiers of study participants were included in data collection forms.

Results
. . Sociodemographic Characteristics of PLWHA Who Are on ART in Kolladiba Health Center. A total of 358 ART clients were participated in the study with response rate of 91%. Among study participants 138 (38.5%) were in the age category of 35-44 years. About 216 (60.3%) of the participants were female while 142 (39.7%) were male. More than half of the respondents 209 (58.4%) came from urban area. Among the respondents 325 (90.8%) were Orthodox followers. Around 124 (34.6%) of the study participants were housewives followed by private employee 95 (26.5%). Half (185, 51.7%) of the respondents were married. From those participants included in the study, 146 (40.8%) were unable to read and write (Table 1).
. . ART Related Characteristics. Two hundred thirty (64.2%) of the respondents had received ART for more than three years. According to health care providers report of 358 study subjects, about 293 (81.8%) have had improved health status after initiation of ART and 289(81.0%) of the participants had knowledge that ART can reduce HIV transmission ( Table 2).

. . Sexual Behavior and Condom Use of ART Clients.
Most of the respondents were sexually active. About three-fourths (270, 75.4%) of the respondents had had sex in the last three months of which 179 (66.3%) had sex with their regular spouse/cohabit partner and 231 (85.6%) had used condom.

. . . Bivariate Analysis of Sexual Behaviors of Respondents with Consistent Condom
Use. The chance of consistent condom use among respondents who had regular boy or girl friend was 0.123 times less likely than respondents who had regular spouse/cohabit (COR=0.123, 95% CI: 0.034,0.451). The odds of consistent condom use among the respondents who use condom by pressured partner were 0.053 times less likely than who use condom to prevent pregnancy (COR=0.053, 95% CI: 0.010,0.288). The chance of consistent condom use initiated by respondent him/herself was 10.8 times and 30.4 times more likely than condom use initiated by sexual partner and mutual decision, respectively.
The respondents whose partner had positive HIV serostatus and unknown serostatus were 0.127 and 0.220 times less likely to use condom consistently than those who have negative serostatus of their partner, respectively.
The respondents who did not disclose their serostatus to their partner were 0.27 times less likely to use condom consistently than those disclosed their HIV serostatus to their partner (COR=0.274, 95% CI: 0.1O2, 0.735).
The odds of inconsistent condom use among respondents who had the desire to have children were 1.863 times more likely than who did not have desire to have children ( COR=1.863, 95% CI: 1.096,3.166) ( Table 5).

. . . Multivariate Analysis of Consistent Condom Use with Important Variables.
Those variables having p-value <0.02 in bivariate analysis were taken into account in this model. In multivariate analysis place of residence and condom use initiated by sexual partner during sexual contact have been found to have an association with consistent condom use.
Respondents in rural residence were 0.326 times less likely to use condom consistently than respondents in urban

Discussion
Condom use is a critical component in a comprehensive and sustainable approach to the prevention of HIV and other sexually transmitted infections (STIs) and for preventing unintended pregnancies especially among people with HIVpositive clients. The maximum protective effect of condoms is achieved when their use is consistent rather than occasional. Inconsistent use/nonuse of condom by PLWHA on ART will lead to further worsening the HIV infection epidemic and reinfection with new drug resistant viral strains. Among sexually active respondents, 130 (55.8%) had used condom consistently in the past three months. The main reasons that respondents reported for not using condoms consistently were the assumption that they are already infected 35 (35.7%), positive status of their sexual partner 30 (30.6%), their opinion that condom reduces sexual pleasure 13 (13.3%), desire to have children 10 (10.3%), and partner refusal 9 (9.2%).
The level of consistent condom use was in line with the study done in Mekelle [8] and Kenya [9], 55.7% and 57.4%, respectively, but the result is lower than in studies done in London, Guatemala, South Africa, Uganda, and Gondar (73.0%, 81.7%, 75.8%, 65.0%, and 78.9%, respectively). The differences might be due to low educational status of the rural population in our study area, their negligence and carelessness to use condom, and lack of condom at a time of causal sexual contact. And it might also be due to lack of professional's commitment to create awareness on PLWHA on ART to use condom consistently.
The important factors associated with consistent condom use in this study were respondent's residence and condom use initiator. Consistent condom use was found to be less likely among PLWHA on ART who were in rural (AOR=0.326 96% CI: 0.109, 0.973) residence than in urban residence. This is in line with a study done in Gondar in which it was found that ART clients in rural residence were less likely to use condom consistently [10]. This could be due to information gap between urban and rural areas, lack of awareness, inadequate information about condom use, and lower educational status of rural population.
Among the participants, the chance of consistent condom use initiated by sexual partner (AOR=0.031, 95% CI: 0.005, 0.186) was less likely than condom use initiated by respondent him/herself. To our knowledge, this has not been previously reported.
Unlike other African studies [4,7,[9][10][11][12] that have reported participants with higher educational status more likely to use condoms consistently compared to lower educational status participants, our study did not show any significant association between educational status and consistent condom use.
The main reasons for not using condom consistently mentioned were the assumption that HIV infected individuals do not need condoms since they are already infected (35.7%), positive status of their sexual partner (30.6%), their opinion that condom reduces sexual pleasure (13.3%), desire to have children (10.3%), and partner refusal (9.2%). Among these main reasons the assumption that HIV infected individuals do not need condoms since they are already infected, partner refusal, and desire to have children were in line with a study done in Mekella [8] and Bahr Dar   [13]. Assumption that HIV infected individuals do not need condoms since they are already infected is also in line with a study done in Gondar [10]

Conclusion
In this study, we found out that consistent condom utilization among HIV clients on ART was low (55.8%). Place of residence and condom use initiation during sexual contact were significantly associated with consistent condom use.

AIDS:
Acquired Immune Deficiency Syndrome ART: Antiretroviral Therapy AOR: Adjusted odd ratio COR: Crude odd ratio HAART: Highly active antiretroviral therapy HIV: Human Immune Deficiency Virus PLWHA: People living with HIV/AIDS SPSS: Statistical package for the social science

Data Availability
The data used to support the findings of this study are included within the article.

Disclosure
The research did not receive specific funding but was performed as part of the employment of the authors, University of Gondar.

Conflicts of Interest
The authors declare that they have no conflicts of interest.

Authors' Contributions
Mohammed Seid Ali theorized the research problem, designed the study, conducted field work, analyzed the data, and revised the manuscript. Mekibib Kassa was involved in data analysis, preparation, and revision of the manuscript for publication. Eleni Tesfaye was involved in supervision of field work, the revision of the research design, statistical analysis, and preparing the manuscript. Kaleab Tesfaye contributed to the revision of the research design, statistical analysis, and preparing the manuscript.