Kirakoya-Samadoulougou et al.

BMC Public Health 2013, 13:540

http://www.biomedcentral.com/1471-2458/13/540

RESEARCH ARTICLE Open Access

Voluntary HIV testing and risky sexual behaviours

among health care workers: a survey in rural and
urban Burkina Faso
Fati Kirakoya-Samadoulougou1*, Seydou Yaro2, Alain Deccache3, Paulin Fao2, Marie-Christine Defer2,
Nicolas Meda2,4, Annie Robert1 and Nicolas Nagot5

Abstract
Background: Voluntary counselling and testing (VCT) together with a safe sexual behaviour is an important
preventive strategy in the control of HIV. Although Health care workers (HCWs) are critical in the response to HIV,
little is known about VCT and high risk behaviours (HRB) among this group in West Africa. This study aims to assess
the prevalence of VCT and HRB among HCWs in Burkina Faso.
Methods: We collected data through a questionnaire in urban areas (Ouagadougou and Bobo-Dioulasso) and rural
areas (Poni and Yatenga) among HCWs from 97 health care facilities. Urine samples were collected, screened for
HIV using a Calypte® test kit and confirmed by Western Blot. Multiple logistic regression analysis was performed to
identify factors associated with the use of VCT services and with high-risk sex behaviour.
Results: About 92.5% of eligible HCWs participated (1570 out of 1697). Overall, 38.2% of them (34.6% of women
and 42.6% of men) had ever used VCT services. About 40% of HCWs reported that fear of knowing the test result
was the main reason for not doing the HIV test. Male HCWs (p = 0.001), laboratory workers (p < 0.001), those having
two years or more experience (p = 0.03), and those who had multiple partners (p = 0.001) were more likely to have
tested for HIV. One fifth of HCWs reported multiple partners. Of these, thirteen percent did not use condoms. HCWs
who had multiple partners were significantly more likely to be men, single, living in rural areas, and under the age
of 29 years.
Conclusion: VCT was still very low among HCWs in Burkina Faso, while HRB was high.
These findings suggest that ‘HCW-friendly’ VCT centres should be implemented, securing confidentiality among
colleagues. In addition, refreshment courses on HIV risk reduction, counselling and testing are certainly required
during the professional career of HCWs.
Keywords: VCT, High-risk sex, Health care workers

Background [3] and transport workers [4]. Key public sectors of de-
In Sub-Saharan countries, the HIV/AIDS epidemic has velopment such as Education and Health are also
eroded more than two-thirds of the Gross Domestic concerned with this negative impact of HIV/AIDS [5].
product, by reducing agricultural- [1] and companies For public health professionals, the HIV pandemic has
production [2]. This loss in productivity has been docu- increased the demand for health workers, and efforts to
mented in some specific private sectors like mine scale up HIV prevention, treatment and care rely on the
workers, [2] business workers, [2] construction workers, size and capacity of national health workforces. At the
same time, the increased global commitment to HIV
puts more pressure on bottlenecks created by health
* Correspondence: [email protected]
1
Pôle Epidémiologie et Biostatistique, Institut de Recherche Expérimentale et
workforce shortages, especially in Sub-Saharan Africa
Clinique (IREC), Faculté de Santé Publique (FSP), Université catholique de where HIV intervention targets remain unmet [6-8]. In
Louvain (UCL), Brussels, Belgium light of this, strengthening and expanding the health
Full list of author information is available at the end of the article

© 2013 Kirakoya-Samadoulougou et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms
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distribution, and reproduction in any medium, provided the original work is properly cited.
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workforce has been identified as a global challenge to were obtained from the Ministry of Health. A number-
scaling up HIV services [9,10] and the commitment to ing system of survey areas, structures and potential sub-
meeting this challenge has been renewed. jects was established. HCWs were selected between
Voluntary HIV testing (VCT) serves as an entry point January and December 2003 in 97 health care facilities.
to HIV/AIDS prevention, care, and support [11]. People For rural areas (province of Poni and Province of
unaware of their HIV infection cannot access effective Yatenga), all health facilities were visited without selec-
treatment, or at a very late stage, and there is evidence tion to achieve the sample size. HCWs from urban areas
that people who are aware of their HIV status can adopt (Ouagadougou and Bobo-Dioulasso: the two biggest
practices to reduce HIV transmission [12,13]. Knowledge towns in the country) were selected by random sampling
of HIV status remains inadequate: based on 10 with probability proportional to size, the size being the
population-based surveys conducted in 2007–2009, the number of health agents by health facilities.
median percentage of people living with HIV who know About 92.5% of eligible health workers participated
their status was below 40% [14]. (1570 out of 1697); 100% from Province of Yatenga,
In Burkina Faso, VCT in the general population re- 96.3% from Ouagadougou, 94.9% from Province of Poni
mains very poor. Data from the last demographic and and 84.1% from Bobo-Dioulasso. Ethical clearance was
health survey, showed that only 22% of men and 30% of sought and obtained from the Regional Committee for
women aged 15–49 have ever been testing for HIV, Medical Research Ethics before data collection. The
among them, 20% and 29% knew their HIV status, re- study purpose was discussed with the participants, and
spectively [15]. after informed consent was obtained, demographic
In Burkina Faso as in most African countries, HCW characteristics and informations about HIV testing
should play a great role in informing their patients were collected through an anonymous questionnaire
on HIV and the benefits of HIV testing, particularly administered by an experienced sociologist. Question-
when those patients are at risk (multipartnership, STIs, naires were validated by a 2-month period of field ob-
etc. …).. However, there is concern that this informa- servation and interviews with 30 HCWs in other
tion on HIV and by extension on sexual and reproduct- schools. The questionnaire solicited respondents’ socio-
ive health is rarely given to patients. Given HCWs are demographic information including health facility, loca-
also at risk through professional and sexual exposure tion, sex, age, marital status, HIV testing and sexual
[16,17], their level of VCT utilisation for themselves behaviour. Participants were asked the question,
would be a good indicator of their awareness and ability ‘Have you ever been voluntarily tested for HIV to learn
to address this issue. your HIV status?’ (Yes or no). This question meant HIV
Moreover, despite the obvious negative effects of the testing in VCT services which always include pre-
epidemic on the health sector, no data are available in test and post-test counselling in Burkina Faso. Our
West Africa on the level of sexual risk for HIV among dependent variables measured risky sexual behaviour in
health care workers, and also on their uptake of HIV two ways: i) number of partners, other than husband or
testing, which are crucial to inform HIV control long-term partner, in last 12 months (high-risk sex),
programmes. The focus of this study is therefore to as- and ii) the use of a condom during last intercourse with
sess the proportion of VCT users and the prevalence of an occasional partner.
high-risk sex (partners other than husband or long-term Urine samples were obtained from health agents.
partner in the last 12 months) among HCWs, together These samples were screened for HIV using a Calypte
with factors associated with HIV testing. test kit and confirmed by Western blot. Twice-reactive
samples by Calypte and Western blot were considered
Methods HIV-positive. We used an anonymous linked approach
The study was part of a national survey that aimed at es- whereby the HIV results could not be given back to par-
timating the prevalence of HIV among health care ticipants. The latter were encouraged to get a free HIV
workers. Based on an expected prevalence of HIV of 4% test and referred to a VCT centre if they wished to know
and a 95% confidence level, the required sample size was their HIV status. Only ID numbers were used in the
1476 to get a 1% precision on prevalence estimate. As- questionnaire and matched urine samples.
suming an acceptability rate for anonymous urinary HIV Chi2 tests, Fisher’s exact tests and Student’s t-tests
testing of 65%, the required sample size was 2270 were used for comparisons at a significance level of
people. Working with 4 provinces, we planned to recruit 5%. Multiple logistic regression analysis was performed
600 participants per province, i.e. 2400 overall. Before to identify factors associated with the use of VCT ser-
the study began, the latest statistics on the number of vices or high-risk sex by checking possible co-linearity
structures, the number of staff and nominal lists by ac- and interactions. The data were analysed using SAS
tivity and addresses of all HCWs in the selected areas version 9.3.
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Results no variations across age groups (p =0.15), regions (p =

Because of low rate participation among 500 medical 0.20), marital status (p = 0.07), and perception of profes-
doctors (<1%), this report is based on data from non sional vulnerability for HIV (p = 0.12) (Table 1). HIV
medical doctors. testing was higher in HCWs who reported high-risk sex
than HCWs who did not had a high-risk sex (p = 0.001)
Sample characteristics (Table 1). In multivariable logistic regression analysis
Among the 1570 HCWs enrolled, 38.2% were from (Table 1), male sex, working in laboratory, job duration
Ouagadougou, 32.0% from Bobo-Dioulasso, 18.9% from and high-risk sex were associated with an increased ac-
Province of Yatenga, and 10.9% from Province of Poni. cess to HIV testing.
The average age of respondents was 34 years (range,
20–60 years), and the majority were women (55.1%).
Sexual behaviours
The mean duration of employment was 10 years
About 21% of HCWs reported having had sex with non
(range, 1–38 years). HCWs were composed of nurses
regular partners over the last 12 months. Of these,
(30.1%), specialist nurses called “Attaché de santé”
10.0% reported more than one sexual partner. A sexual
(7.8%), auxiliary nurses called “agents itinérant de
encounter with a non regular partner was more frequent
santé” (6.5%), midwives or auxiliary midwives (21.7%),
among male HCWs than among female HCWs (p <
students and trainees (STU) (15.0%), administrative
0.001). In addition, a higher percentage of HCWs in the
and manual workers (ADM) (17.5%) and laboratory
youngest age group, single HCWs, students and trainees
workers (2.4%). For all analyses, job categories were
reported having sexual intercourse with non regular
collapsed into nurses/midwives (NUR/MID) (66.1%),
partners (Table 2). The proportion of HCWs who
STU (16.4%), laboratory (2.2%), administrative and
reported having had sex with non regular partners
manual workers (15.2%).
tended to be higher among HCWs from rural areas than
Of respondents, 68.6% were married or living with a
among HCWs from urban areas (23.4% versus 19.3%,
regular partner, 23.8% were single and 7.6% were di-
p = 0.07). Results of univariate and multivariate analysis
vorced, separated or widowed. Overall, 75.8% of HCWs
for high-risk sex were unchanged when adjusting ana-
had a good knowledge of the main routes of HIV trans-
lyses for gender, location, marital status, age, job cat-
mission (unprotected sexual intercourse, direct injection
egory, professional vulnerability, and HIV status.
with HIV-contaminated needles, syringes, blood or
Thirteen percent of teachers who had sex with a non
blood products, mother to child transmission through
regular partner did not use condoms. More female
pregnancy, delivery or breastfeeding) and more than
HCWs than male HCWs did not use a condom in their
42.0% of HCWs had a poor knowledge of the mecha-
last high-risk intercourse (16.7% versus 7.5%, p = 0.02).
nisms of HIV prevention (Abstinence and safe sex, pre-
Single HCWs were less likely to use a condom at last
cautions regarding the using of needles, syringes, blood
sex with an occasional partner than married HCWs
or blood products).
(22.4% versus 15.7%, p < 0.001). There were no associ-
The majority (96.5%) of interviewed HCWs have con-
ation between condom use and age groups (p = 0.41),
sidered their occupation as being at risk of contracting
job category (p = 0.56), employment duration (p = 0.62)
HIV/AIDS (professional vulnerability for HIV).
or HIV status (p = 0.22).
The overall prevalence of HIV among HCWs was
3.5% (95%CI: 2.3 – 4.6) with 2.7% (95%CI 1.3 – 4.2) for
male HCWs and 4.1% (95%CI 2.4 – 5.8) for female Discussion
HCWs (p = 0.13). Our study is the first to investigate VCT uptake services
and sexual behaviour among HCWs in a representative
HIV testing sample in West Africa. The findings revealed a low rate
Overall, 38.2% (n = 1570) of individuals (34.6% of women of HIV testing among HCWs in Burkina Faso. Neverthe-
and 42.6% of men, p = 0.001) had ever used voluntary less, this rate of testing for HIV was slightly higher than
counselling and testing services (VCT). The majority of that of the general population as reported in the Burkina
HCWs had tested for HIV at private laboratories Faso Demographic and Health Survey in 2003 [18]
(63.0%), at a government health facility (22.5%), and Zungu Li et al. [19] reported that 91% of HCWs in
public laboratories (14.5%). Fear of knowing the out- South Africa had been tested for HIV. Such findings in
come was the main reason given for not taking the HIV South Africa are in line with other studies that reported
test, as reported by 40.0% of HCWs. More HCWs work- a high level of HIV counselling and testing uptake
ing in laboratories had reported more HIV testing than among healthcare workers [20,21]. However, a study in
other HCWs (p = 0.001) (Table 1). Among HIV-infected Zambia among HCWs founded a low level of HIV coun-
individuals, only 40.0% ever tested for HIV. There were selling and testing uptake (33%) [22].
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Table 1 Univariable and multivariable analysis of having testing for HIV by socio-demographic, sexual behaviour, and
HIV infection
Total n Users of VCT% Univariable OR(95%CI)* Multivariable** OR(95%CI)
Gender
Men 705 42.6 1.4 (1.1 – 1.7) 1.4 (1.1 – 1.6)
Women 865 34.6 1 1
Age (years)
≤24 115 35.7 1.1 (0.7 – 1.8) 1.1 (0.7 – 1.6)
25-29 338 39.1 1.3 (0.9 – 1.8) 1.2 (0.9 – 1.7)
30-34 370 41.6 1.4 (1.0 – 2.0) 1.4 (1.0 – 2.1)
35-39 264 37.5 1.2 (0.8 – 1.7) 1.2 (0.7 – 1.6)
40-44 223 39.0 1.3 (0.9 – 1.9) 1.2 (0.9 – 1.8)
>44 260 33.1 1
Geographical location
Rural 467 35.8 1 1
Urban 1103 39.2 1.2 (0.9 – 1.4) 1.2 (1.0 – 1.3)
Marital status
Single 493 41.4 1.2 (0.9 – 1.5) 1.1 (0.8 - 1.4)
Married or living in couple 1077 36.7 1 1
Job category
Nurses /Midwives 1038 39.9 1 1
Students and trainees 258 37.6 0.9(0.7 – 1.2) 0.9(0.8 – 1.2)
Laboratory workers 35 82.9 7.3 (3.0 – 17.7) 7.1 (2.9 – 17.6)
Administrative and manual workers 239 24.7 0.5 (0.4 – 0.7) 0.5 (0.4 – 0.8)
Years of work experience
≤ 1 year 288 31.5 1 1
2 – 10 years 1050 39.3 1.4 (1.1 – 1.9) 1.4 (1.1 – 1.8)
>10 years 230 41.2 1.5 (1.1 – 2.2) 1.5 (1.1 – 2.2)
Professional vulnerability for HIV***
Not vulnerable to HIV 45 35.6 0.9 (0.5 – 1.6)
Vulnerable to HIV 1515 38.4 1
Don’t know 10 10.0 0.2 (0.02 – 1.4)
High-risk sex****
Yes 312 46.2 1 1
No 1200 36.3 0.7 (0.5 – 0.9) 0.7 (0.4 -0.9)
Condom at last sex (with occasional partner)
Yes 272 44.1 0.5 (0.3 – 1.0) 0.4 (0.3 – 1.0)
No 40 60.0 1 1
HCWs HIV-infected
Yes 35 40.0 1 1
No 978 38.0 0.9 (0.5 – 1.8) 0.8 (0.5 – 1.7)
No sample 557 38.2 0.9 (0.5 – 1.9) 0.7 (0.6 – 1.7)
* Odds ratio (95% confidence interval).
** Covariates in multivariable logistic regression: gender, location, marital status, age, schools, high-risk sex and HIV infection.
*** HCWs who perceived their occupation vulnerable for HIV.
**** Having a non-cohabitating, non-marital sexual partner in the last 12 months (occasional partner).
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Table 2 Univariate and multivariate analysis of high-risk sex by socio-demographic and HIV infection
Total n High-risk sex§% Univariable OR(95%CI)* Multivariable* OR(95%CI)
Gender
Men 678 34.2 4.9 (3.7 – 6.5) 4.9 (3.6 – 6.4)
Women 834 9.6 1 1
Age (years)
≤29 410 39.5 7.3 (4.5 – 12.1) 7.4 (4.6 – 11.1)
30-34 361 18.6 2.5 (1.5 – 4.3) 2.6 (1.4 – 4.1)
35-39 264 14.8 1.9 (1.1 – 3.4) 1.8 (1.1 – 3.1)
40-44 222 10.4 1.3 (0.7 – 2.4) 1.2 (0.7 – 2.3)
>44 255 8.2 1 1
Marital status
Single 435 48.8 9.3 (7.0 – 12.3) 9.1 (7.0 – 11.0)
Married or living in couple 1077 9.3 1 1
Geographical location
Rural 449 23.4 1.3 (1.0 – 1.7) 1.2 (0.9 – 1.6)
Urban 1063 19.3 1 1
Job category
Nurses/ Midwives 1020 17.3 1 1
Students and trainees 229 43.7 3.7 (2.7 – 5.1) 3.4 (2.6 – 5.0)
Laboratory workers 34 20.6 1.2 (0.5 – 2.8) 1.2 (0.4 – 2.6)
Administrative and manualworkers 229 12.7 0.7 (0.4 – 1.1) 0.6 (0.4 – 1.1)
Years of work experience
<1 year 200 22.5 1.5 (0.9 – 2.4)
2 – 10 years 1162 20.4 1.0 (0.7 – 1.6)
>10 years 150 20.0 1
Professional vulnerability for HIV***
Not vulnerable to HIV 41 24.4 1
Vulnerable to HIV 1460 26.8 1.1 (0.7 – 2.4)
Don’t know 11 0.0 ———
HCWs HIV-infected
Yes 35 11.8 1 1
No 970 22.1 2.2 (0.8 – 7.4) 2.3 (0.7 – 7.1)
No sample 507 18.5 1.8 (0.7 – 6.0) 1.6 (0.6 – 5.4)
§ Having a non-cohabitating, non-marital sexual partner in the last 12 months (occasional partner).
* Odds ratio (95% confidence interval).
** Covariates in multivariable logistic regression: gender, location, marital status, age, schools, and HIV infection.
*** HCWs who perceived their occupation vulnerable for HIV.

Fear of HIV test results was the major reason stated There is a high female-to-male difference in the use of
by participants for not undergoing HIV testing. Simi- HIV testing in Burkina Faso HCWs. Male HCWs were
larly, a UK-based study showed that that fear of results more likely to have been tested for HIV than female
and fear of colleagues’ reactions were the main reasons HCWs. Data from the demographic and health surveys
for not undergoing HIV testing [23]. Proximity to a on prior HIV testing experience, suggest higher testing
clinic [24], perception of being at risk of HIV infection, among females in West African countries, [18,27-29]
[25,26] psychosocial factors such as HIV/AIDS-related and in South Africa [30-32]. However, according to the
stigma and discrimination, [24,25] and concerns about 2005 Ethiopia Demographic Health Survey, 4% of
confidentiality [24,25] are possible factors associated women and 6% of men had ever been tested for HIV
with VCT uptake. [33]. Studies conducted in Zambia, Zimbabwe and the
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UK reported that acceptance of HIV testing was lower were significantly related to high-risk sex behaviours,
among women than men [20,34,35]. The Zimbabwean which is consistent with previous findings among the
study specifically reported that women were allegedly general population [18].
more worried about their HIV status and more fearful of The non-response rate was low, which ensures that
HIV testing than men [34]. the sample is representative of the target population.
Our study also showed that VCT service utilization All data in the survey were self-reported. Therefore,
among HCWs in Burkina Faso was the highest among some degree of under-reporting of socially unaccept-
laboratory workers. Laboratory workers are exposed to able behaviours and over-reporting of socially desirable
occupational injuries, exposing to blood-borne patho- behaviours are likely. It should also be noted that this
gens. In the study among HCWs in South Africa, the study has been based on data collected in 2003, and
majority of HCWs stated that they went for HIV coun- since then the absolute level of HIV testing experience
selling and testing afterwards, mainly to determine their among HCWs is likely to have changed substantially
HIV baseline status [19]. In fact, in this study, the group along with improved access to HIV testing in the coun-
which is less exposed to occupational injury, the admin- try. However, these data is the first epidemiological sur-
istrative and manual workers are less likely have tested vey in West Africa addressing HIV testing and risky
to HIV infection. behaviours among HCWs.
The results of this study also showed a significant asso-
ciation between undergoing HIV counselling and testing, Conclusion
and participants working experience. Not surprisingly, the HIV testing in HCWs in Burkina Faso appears relatively
more experienced were HCW, the more they had been low with high risky behaviors. It seems influenced by job
tested for HIV. category, working experience and sexually risky behaviors,
HCWs with sexually risky behaviours were more likely along with fear of the result. These findings suggest that
to have used VCT services, as reported by previous stud- ‘HCW-friendly ’ VCT centres should be implemented, se-
ies, [36] suggesting a good self-perception of HIV risk in curing confidentiality among colleagues. In addition, re-
this group. freshment courses on HIV risk reduction, counselling and
Among HIV-infected individuals, more than half never testing are certainly required during the professional car-
tested for HIV. Studies investigating the outcome of eer of HCWs.
VCT in Africa demonstrated a beneficial impact of VCT
in HIV-related sexual risk behaviours [36-39]. In a meta- Abbreviations
HIV/AIDS: Human Immunodeficiency Virus/ Acquired Immune Deficiency
analysis, the odds of reporting increased number of sex- Syndrome; VCT: Voluntary counselling and testing for HIV; HRS: High-risk sex.
ual partners were reduced when comparing participants
who received VCT with those who did not [38]. When Competing interest
stratified by serostatus, these results remained significant The authors have no competing interests to declare.

for those who tested HIV-positive. Additionally, people Authors’ contributions

living with HIV who received VCT exhibited increased The overall study was designed by NN, SY, PF and MCD with input from NM.
odds of using condoms and engaging in protected sex The field data collection was led by FP and supported by SY and NN. The
lab work was done by FKS under the supervision of MCD. FKS carried out all
than people living with HIV who did not receive VCT data analyses; FKS and AR interpreted results of statistical testing and made
[38]. Moreover, previous studies suggested that HIV coun- inferences. The manuscript was prepared by FKS, NN, AD, SY, PF, MCD, NM
selling and testing of individuals and couples is a cost- and AR. All authors read and approved the final manuscript.
effective primary HIV prevention strategy [11,40,41]. In
Acknowledgments
our study, the proportion of high-risk sex tended to be We thank the head of each health care facility where the study took place
lower among HIV-infected HCWs compared those who and the staff of Centre Muraz for their invaluable assistance and cooperation.
were not infected or with no urine sample, but without We wish to acknowledge the health care workers for their extraordinary
participation. This project was funded by the United Nations Development
reaching statistical significance. Programme (UNDP), World Health Organization (WHO), the United Nations
Sex with non regular and/or multiple partners was Population Fund (UNFPA), Embassies of Holland, Switzerland, Denmark, and
considered as risky sexual behaviours. About one out of Belgium.
Technical assistance was provided by the Ministry of Health and the National
five interviewed HCWs reported having had sex with a AIDS Control Programme.
non regular partner within the 12 months preceding the
survey. Regional disparities revealed also that sex with Author details
1
Pôle Epidémiologie et Biostatistique, Institut de Recherche Expérimentale et
non regular partners was reported mostly in rural areas, Clinique (IREC), Faculté de Santé Publique (FSP), Université catholique de
a situation that could be attributed to the separation Louvain (UCL), Brussels, Belgium. 2Centre Muraz, Bobo-Dioulasso, Burkina
from families and poor social support throughout the Faso. 3Institut de recherche santé et société (IRSS), Faculté de Santé Publique
(FSP), Université catholique de Louvain (UCL), Brussels, Belgium.
year. Younger people are involved in more sexually risky 4
Département de santé publique, Université de Ouagadougou,
behaviours than adults. Gender, age, and marital status Ouagadougou, Burkina Faso. 5INSERM U1058 «Infection by HIV and by agents
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with mucocutaneous tropism: from pathogenesis to prevention, Université cluster-randomized trial of two strategies providing voluntary counselling
Montpellier 1 & CHRU Montpellier, Montpellier, France. and testing at the workplace, Zimbabwe. AIDS 2007, 21:483–489.
21. Kruse GR, Chapula BT, Ikeda S, Nkhoma M, Quiterio N, Pankratz D, Mataka K,
Received: 12 November 2012 Accepted: 11 March 2013 Chi BH, Bond V, Reid SE: Burnout and use of HIV services among health
Published: 5 June 2013 care workers in Lusaka District, Zambia: a cross-sectional study. Hum
Resour Health 2009, 7:55.
22. Kiragu K, Ngulube T, Nyumbu M, Njobvu P, Eerens P, Mwaba C: Sexual risk-
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