Utilization of HIV and Sexually Transmitted Infections Prevention Services, and Associated Factors among the Long-Distance Truck Drivers along the Northern Corridor Highway, Kenya

Background: Often, long-distance truck drivers’ (LDTDs’) work predisposes them to sexually transmitted infections (STIs) whose outcomes are influenced by access and behavior of seeking sexual health care. Methodology: In this study, we assessed the utilization of HIV/STI preventive services and associated factors among 296 LDTDs operating along the northern corridor highway using an interviewer-administered questionnaire for data collection at Mlolongo stopover in Machakos, Kenya. Responses for the investigated variables, including condom use, history of HIV testing, frequency of HIV testing, antiretroviral therapy (ART) use and follow-up for the HIV positive and STI treatment, were assigned a score of either 1 or 0 depending on the question’s dimension. Following summing up for each participant, we computed a weighted score ranging between 0 and 1 by dividing the summed responses by the number of eligible variables. We arbitrarily multiplied these scores by 8 to generate endpoint scores ranging from one to eight for each participant to help create a dichotomized outcome variable for utilization levels: limited utilization (1 to 4) and good utilization (5 to 8). Association between certain independent variables and the outcome variable (level of utilization of H.I.V./STIs preventive services) was analyzed using binomial logistic regression analysis in R statistical software. Results: The mean age of the LDTDs was 38.4 years, ranging from 24 57 years. The majority (n = 287, 97%) of the LDTDs had been tested on HIV at least once since the beginning of their career. Only 4.9% of the LDTDs had been tested on HIV within the previous three months. Of the 175 LDTDs who reported a history of STI, most (n = 173, 98.9%) of them had sought treatment. Condom use rates were higher How to cite this paper: Mutie, C., Kairu-Wanyoike, S., Mambo, S., Ngoge, R. and Gachohi, J. (2021) Utilization of HIV and Sexually Transmitted Infections Prevention Services, and Associated Factors among the Long-Distance Truck Drivers along the Northern Corridor Highway, Kenya. Advances in Sexual Medicine, 11, 39-58. https://doi.org/10.4236/asm.2021.113003 Received: April 22, 2021 Accepted: June 1, 2021 Published: June 4, 2021 Copyright © 2021 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access


Introduction
Long-distance truck drivers (LDTDs) are central to the challenges faced in the fight against HIV and sexually transmitted infections (HIV/STIs) in large part due to escalated risk of new infections arising from the nature of their career [1] [2]. Moreover, the risk of HIV and STI infection outcomes among the LDTDs is partly attributable to sub-optimal access and underutilization of HIV/STI preventive services [3]. These two factors (heightened risk and underutilization of HIV/STI preventive services) have placed the LDTDs among at-risk populations that need targeted interventions for effective control of HIV [1].
Evidence that LDTDs do not adequately utilize the HIV/STI preventive services, especially when on transit is available. For instance, in Mozambique, Botao et al. [4] reported that only 65.8% of the LDTDs had been tested on HIV. Likewise, in Togo, Yaya et al. [5] described 47.4% of LDTDs that had accessed HIV testing previously. In Nigeria, Atilola et al. [6] identified low utilization levels (36.4%) of HIV testing among the LDTDs. A study in South Africa reported a low uptake of STI treatment services among LDTDs who frequented wellness clinics [3]. In Kenya, a study reported a paltry 1.3% of LDTDs taking self-driven HIV testing [7].
Key challenges continue to negatively shape the utilization of HIV/STI preventive services among LDTDs. Lack of adequate health facilities and services specifically tailored for the LDTDs has impaired their smooth access to STI treatment in Pakistan [8]. In a study conducted in Mozambique, 75% of the LDTDs interviewed had not received free condoms, lubricants, and HIV/STI preventive information in the previous 12 months [4]. In New Mexico, study respondents disclosed that lack of health insurance cover, mistrust, lack of confidentiality from health care providers, and inability to keep hospital appointment dates hindered them from meeting their health care needs [9]. In Zambia, tight work schedules, with very little time to rest among LDTDs posed difficulties in utilizing HIV/STI preventive services [10]. Recently, delays due to COVID-19 clearance requirements among LDTDs could have adversely affected their uptake of key public health services [11].
The low utilization of HIV/STIs preventive services among the LDTDs has been linked to a high HIV prevalence among them. To illustrate this, a study done at Kwa-Zulu Natal in South Africa along the North-South Corridor highway revealed an HIV prevalence of 56% among the LDTDs [12]. In Uganda, the LDTDs had an HIV prevalence ranging between 25% to 32% [13]. A similar population had an HIV prevalence of 17.8% in Kenya [14].
While the existing literature shows limited utilization of HIV/STI preventive services among the LDTDs, opportunities exist to optimize the uptake. In Tanzania, a dated study explained that peer interventions among the LDTDs could improve the utilization of condom use by 50% -74% [15]. Literature shows that offering oral HIV testing among the LDTDs in Kenya at the wellness centers along the highway improved HIV testing uptake [16]. Information on the availability of HIV testing via mobile phone text has also been shown to increase the uptake of these services among LDTDs in Kenya [7].
Nevertheless, data on the uptake of HIV/STI preventive services among the LDTDs in Kenya is scanty. This study, therefore, sought to assess the levels of utilization of HIV/STI preventive services and associated factors among the LDTDs who operate along the northern corridor highway in Kenya. This study could aid the policymakers involved in HIV programming in improving the current policies in the fight against HIV and other STIs among the LDTDs.

Research Design
We conducted a cross-sectional study among LDTDs who made a stop at a wayside weighbridge in Mlolongo town in Machakos, Kenya, between July and August 2020. Besides taking the weight of the trucks, the town is a key destination for commercial sex work and offering restful accommodation services [17]. Therefore, this was a suitable site for our study, given that almost all LDTDs have to make a stopover there. The sample size of the study participants, calculated using formal sample size calculation procedures, was 296. We applied a systematic sampling technique using a daily sampling size of 21 and a sampling interval of 20 to sample the LDTDs.

Data Collection Instruments
We implemented an interviewer-administered questionnaire as a tool for data collection. The study adopted this tool from a World Health Organisation (WHO) generic tool designated for conducting HIV and STIs research [18]. We also consulted the guidelines in previous studies in questionnaire development [19] [20].

Pre-Testing of Data Collection Instruments
The study commenced with a pre-testing of data collection tools at the neighboring Makutano town in Machakos County. The town is used as a stopover for rest and commercial sex but on a significantly lower scale relative to our study site along the Northern Corridor highway. In this exercise, we recruited 30 participants considering the sample size recommended for a study to achieve a power of 80% [21].

Data Collection
The LDTDs were initially approached at a wayside parking towards the exit of the weighbridge for a detailed introduction of the study. Those who expressed willingness to participate in the study were further taken through an informed consent, which they formally signed before the onset of the interview. Given the sensitive nature of some of the questions in our questionnaire, most of the LDTDs understandably requested to be interviewed inside the truck driver's cabin, safeguarding privacy during the interview process. Data on the history and trends of the utilization of HIV/STI preventive services among the LDTDs were collected.

Data Management and Analysis
A database was designed in MS Excel ® , and data from the questionnaires were entered, followed by data cleaning and exportation to the R statistical software [22] for analysis. Descriptive statistics were generated regarding the socio-demographic and socio-economic characteristics, history of HIV and STIs, and levels of utilization of HIV/STI preventive services. A composite outcome variable on utilization of HIV/STIs preventive services was derived from; condom use, history of HIV testing, frequency of HIV testing, antiretroviral therapy (ART) use, and follow-up for the HIV positive and STI treatment. On their own, the individual variables could not give a conclusive level of the utilization of HIV/STI preventive services among the LDTDs, hence the need for the composite variable [23].
The selection of the original variables used to create the composite variable was based on the relevance of the variable in the utilization of HIV/STI preventive services as guided in previous research [23].
Responses from the investigated variables, including condom use, history of HIV testing, frequency of HIV testing, ART use, and follow-up for the HIV positive and STI treatment, were assigned a score of either 1 or 0 depending on the question's dimension. Following summing up for each participant, we computed a weighted score ranging between 0 and 1 by dividing the summed responses by the number of eligible variables. We arbitrarily multiplied these scores by 8 to generate endpoint scores ranging from one to eight for each participant to help create a dichotomized outcome variable for utilization levels: Association between the independent variables and the outcome variable (level of utilization of HIV/STIs preventive services) was determined using binomial logistic regression analysis in R statistical software [22].

Ethical Considerations
Informed consent was sought from each LDTD before commencing the interview exercise. The anonymity of all LDTDs was observed throughout the data collection exercise to ensure confidentiality. The data enumerators were sworn to a confidentiality form before starting the data collection exercise to ensure the privacy of the study participants. Questionnaires were stored in a locked cabinet, while data was stored in coded form and secured with passwords for confidentiality. The ethical review committee of the University of Eastern Africa Baraton (UEAB/REC/10/02/2020) approved this study. Data collection was authorized by the board of postgraduate studies, Jomo Kenyatta University of Agriculture and Technology, Kenya (JKU/2/11/HSH/314-1277/2018). Additionally, the National Commission for Science, Technology, and Innovation, Kenya, issued a license and permit to conduct this study (NACOSTI/P/20/4107). Table 1 shows the socio-demographic and socio-economic characteristics of 296 LDTDs involved in this study. The mean age of the LDTDs was 38.4 years, ranging from 24 to 57 years. The majority of the LDTDs were aged between 35 and 44, whereas the minority were aged between 55 -66 years. The majority of the LDTDs (65.9%) had attained secondary school education, while only 2% had attained a college education. Most (80.4%) of the LDTDs reported that they were married, while in terms of religion, most of them (78.0%) were Christians. Approximately half (49.3%) of the LDTDs had work experience of above ten years, with 96.3% of them earning below 500 US dollars in a month (Table 1).

HIV Testing Trends among the Long-Distance Truck Drivers
The majority (n = 287, 97%) of the LDTDs who were interviewed reported having been tested for HIV at some point since the start of their career. At the time

Challenges Faced in Access to HIV Testing Services
Of the 287 LDTDs who reported HIV testing before, 45.3% of them reported time delays as their main challenge in accessing HIV testing services. In contrast, the minority (7%) cited negative attitudes from health care providers (Table 2).

Antiretroviral Therapy Uptake and Follow up on Care
All the six LDTDs who tested HIV positive before, had been started on antire-DOI: 10.4236/asm.2021.113003 46 Advances in Sexual Medicine troviral therapy (ART) therapy and already on follow-up and care in different health facilities. When asked about the challenges they faced while accessing their ART therapy, three participants reported no challenges at all, two reported having missed one of their scheduled follow-up and ART refill appointments due to delays at the international border points. One LDTD reported having missed one of his follow-up and ART refill appointments at some point when he tested positive for COVID-19 and was isolated for 21 days.

History of Sexually Transmitted Infections and Treatment among the Long-Distance Truck Drivers
A majority (59.1%) of the LDTDs disclosed infections with an STI since their career onset. Of those who reported having ever contracted an STI, majority (98.9%) sought treatment while the rest did not. Of those who reported that they had sought treatment, 96.0% reported doing so within seven days. Approximately half (48.6%) of the LDTDs sought STI treatment from non-governmental health-based facilities. About a third of the LDTDs had never faced challenges while accessing STI treatment services (Table 3).

Condom Use among the Long-Distance Truck Drivers
Of the 141 Long-distance truck drivers who reported sexual interactions, 84.4% of them had used condoms. Slightly below half (47.2%) of the 36 LDTDs who had sexual interaction with regular partners used condoms while the rest (53.8%) did not. The LDTDs who had sexual interactions with casual sex partners had the highest rates of condom use, with 97.1% of them reporting condom use. A majority (81.8%) of the LDTDs reporting no condom use claimed to have not perceived any risk of STI infection during their sexual interactions. Approximately 42.2% of the LDTDs accessed condoms from bars or other entertainment joints while on transit. The majority of the LDTDs (72.6%) had never lacked condoms in a time of need, while the rest reported that at some point, they had lacked condoms when they needed them. Most LDTDs (69.3%) had never experienced challenges while accessing condoms (Table 4).

Utilization Levels of HIV/STIs Preventive Services
From the composite variable we generated, most of LDTDs (78.0%) were classed to have good utilization of HIV/STIs preventive services (5 -8), while the rest (22%) had limited utilization (1 -4).

Utilization of HIV/STI Preventive Services
This study assessed the utilization levels of HIV/STI preventive services and associated factors among the LDTDs. Analyses classed most of the respondents (n = 231, 78.0%) as having good utilization, while the rest (22%) had limited utilization. An STI history was strongly associated (OR > 8) with the utilization of HIV/STI preventive services.
The study findings reveal that despite the high number of LDTDs undergoing HIV testing (97%), the uptake of the subsequent tests (as recommended after every three months) is still low (4.9%). In such circumstances, the identification of new HIV cases among the LDTDs could be difficult. As a result, late HIV diagnosis misses the early initiation to antiretroviral therapy and continues to bridge the infection to other sexual partners. Nevertheless, there is an opportunity to improve the uptake of the subsequent HIV tests to meet the recommended frequency of 3 monthly testing for the most at-risk populations, including LDTDs. The 97% of LDTDs previously tested for HIV in this study are comparable to 91.8% reported in 2018 in Kenya, suggesting recent improvements in national HIV testing among the LDTDs [24]. Studies in Mozambique and Togo reported lower proportions (65.8% and 47.7% respectively) of HIV testing among the LDTDs, perhaps a reflection of lesser national HIV testing [4] [5].
Of the LDTDs previously HIV tested, 95.5% had only received the provider-administered finger prick test. In contrast, only 4.5% of the LDTDs had ever utilized oral HIV tests. This outcome indicates that the oral HIV testing uptake is unacceptably low among the LDTDs, despite strong recommendations from UNAIDS [25]. Research shows that availing the oral HIV test kits to the LDTDs may improve their uptake on HIV testing [7]. Indeed, the reason for their recommendation is the non-invasive nature enabling ease of use without healthcare provider involvement [7]. Therefore, reasons as to the low (4.9%) uptake of the oral HIV tests need to be investigated.
Slightly above half (59.1%) of the LDTDs reported contracting an STI during their career, suggesting minimal condom use during their sexual interactions. However, it was notable that almost all (98.9%) of the LDTDs who contracted the STIs sought treatment. Prompt STI treatment provides a strong prognosis of recovery and reduces chances of HIV transmission between sexual partners. Contrary to our findings, a previous study on the same population conducted a decade earlier found smaller proportions of 15% of LDTDs reporting an STI history, perhaps reflecting a change of practices with time [17].
Most of the LDTDs (78.0%) reported good utilization of the HIV/STI preventive services (scores of 5 -8), while the rest (22%) had limited utilization (scores of 1 -4). The proportion of LDTDs (22%) who had limited utilization highlights the need for enhanced interventions. These interventions need to be tailored to meet the unique healthcare needs of the LDTDs. Policy guidelines on HIV programming (HIV testing, care, and treatment) recommend integrating STI and HIV preventive services like; HIV testing and counselling and condom distribution to the vulnerable groups [26]. Integrating the STI and HIV preventive services has the advantage of improving the overall utilization of the HIV preventive services while being cost-effective [26]. The outcome in utilizing HIV/STI preventive services supports the guidelines for integrating HIV and STI services. Contrary to our findings on 78% of LDTDs reporting good utilization of HIV preventive services, a study in South Africa found that only 30% of the study participants had good utilization [3].
Of the LDTDs who reported sexual interactions with casual sexual partners, 97.1% of them used condoms. For the LDTDs who had sexual interactions with regular sexual partners, only 47.2% of them used condoms. From these findings, it is evident that the exposure risk to HIV and STIs is high among the LDTDs engaging regular sexual partners implying that intense HIV/STI control efforts need to include this segment, previously neglected relative to those engaging in casual sex. Consistent with our findings, previous studies in Nigeria, South Africa, and Mozambique have identified low rates of condom use in sexual interactions between LDTDs and regular sexual partners as opposed to higher rates among casual partners [1] [4] [27].

Factors Associated with the Utilization of HIV/STI Preventive Services
Only the history of STIs among the LDTDs was significantly and strongly associated with the utilization of HIV/STI preventive services (OR = 8.4). These findings imply that the LDTDs who contracted STIs and sought treatment in various health facilities also benefited from other HIV/STI preventive services such as accessing condoms and HIV testing. The findings also suggest that the health care providers who attend the LDTDs should also create awareness of preventing future STIs. Recent guidelines recommend that patients who present with STIs obtain HIV testing to avoid missed opportunities for identifying new HIV cases [25] since STIs elevate the risk of HIV infection. The chances are that the LDTDs presenting with STI symptoms may also have been exposed to HIV attributable to similar transmission mode [26]. While these findings are consistent with those of other studies done in Zambia and Brazil reporting a significant association between STI and utilization of HIV/STI preventive services [28] [29], a study in the USA reported no significant association between the history of STIs and the uptake of HIV preventive services [30]. Our findings suggest that in enhancing the utilization of H.I.V./STIs preventive services, LDTDs should be encouraged to bring along their sexual partners for STI/HIV health care services whenever they have an STI. The ultimate goal would be to maximize the utilization of HIV/STI preventive services among the most at-risk populations and the general population, thus reducing new HIV and STI infections.

Study Limitations
Given the discomfort that may arise from questions touching on sexual interac- tions, responses given by the LDTDs were likely to have social-desirability bias, where respondents over-report the good behavior and under-report the bad behavior. To minimize the social-desirability bias, we ensured that confidentiality prevailed throughout the study while detailing the potential benefits of the study to the LDTDs health well-being during interviews.

Conclusion
Despite the 78% of good utilization of HIV/STI preventive services, uptake of the subsequent HIV testing among the LDTDs is still low at 4.9%, calling for enhanced HIV testing among the LDTDs. The history of an STI among the LDTDs is a predictor of utilization of HIV/STI preventive services. Therefore, a recent history of an STI may open an opportunity for providing other HIV preventive services among the LDTDs like HIV testing and access to condoms.
QC.1 During the time you had penetrative sex (anal or vaginal), did you use condoms?
Yes No Declined to answer QC.2 If NO to QC.1 above, would you share to us your reason for not using condoms?
Lack of perceived risk of H.I.V./STIs infection from the partner Did not have the condoms Need to have maximized pleasure with unprotected sexual intercourse Declined to answer Other specify……………………………………………………. QC.3 What would you say were your reasons for sexual engagement while on transit?
As a way of relieving stress related to nature of trucking work Urge to meet sexual needs due to prolonged separation from wife or regular sexual partner