title: Individual, household and community factors associated with HIV test refusal in rural Malawi.
abstract: OBJECTIVE
  To investigate individual, household and community factors associated with HIV test refusal in a counselling and testing programme offered at population level in rural Malawi.
  
  
  METHODS
  HIV counselling and testing was offered to individuals aged 18-59 at their homes. Individual variables were collected by interviews and physical examinations. Household variables were determined as part of a previous census. Multivariate models allowing for household and community clustering were used to assess associations between HIV test refusal and explanatory variables.
  
  
  RESULTS
  Of 2303 eligible adults, 2129 were found and 1443 agreed to HIV testing. Test refusal was less likely by those who were never married [adjusted odds ratio (aOR) 0.50 for men (95% CI 0.32; 0.80) and 0.44 (0.21; 0.91) for women] and by farmers [aOR 0.70 (0.52; 0.96) for men and 0.59 (0.40; 0.87) for women]. A 10% increase in cluster refusal rates increased the odds of refusal by 1.48 (1.32; 1.66) in men and 1.68 (1.32; 2.12) in women. Women counsellors increased the odds of refusal by 1.39 (1.00; 1.92) in men. Predictors of HIV test refusal in women were refusal of the husband as head of household [aOR 15.08 (9.39; 24.21)] and living close to the main road [aOR 6.07 (1.76; 20.98)]. Common reasons for refusal were fear of testing positive, previous HIV test, knowledge of HIV serostatus and the need for more time to think.
  
  
  CONCLUSIONS
  Successful VCT strategies need to encourage couples counselling and should involve participation of men and communities.
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK. katharina.kranzer@lshtm.ac.uk
authors.forename: Katharina
authors.initials: K
authors.lastname: Kranzer
authors.forename: Nuala
authors.initials: N
authors.lastname: McGrath
authors.forename: Jacky
authors.initials: J
authors.lastname: Saul
authors.forename: Amelia C
authors.initials: AC
authors.lastname: Crampin
authors.forename: Andreas
authors.initials: A
authors.lastname: Jahn
authors.forename: Simon
authors.initials: S
authors.lastname: Malema
authors.forename: Dominic
authors.initials: D
authors.lastname: Mulawa
authors.forename: Paul E M
authors.initials: PE
authors.lastname: Fine
authors.forename: Basia
authors.initials: B
authors.lastname: Zaba
authors.forename: Judith R
authors.initials: JR
authors.lastname: Glynn
mesh_terms: D000293:Adolescent; D000328:Adult; D003376:Counseling / Q000592:standards*; D054541:Family Conflict / Q000208:ethnology / Q000523:psychology*; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000453:epidemiology / Q000523:psychology; D015528:HIV Seroprevalence; D015497:HIV-1; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D045808:Refusal to Participate / Q000208:ethnology / Q000523:psychology*; D012423:Rural Health; D012931:Social Environment; D055815:Young Adult