Mobilization for HIV Voluntary Counseling and Testing Services in Vietnam Clients’ Risk Behaviors, Attitudes and Willingness to Pay

AIDS Behav (2016) 20:848–858 DOI 10.1007/s10461-015-1188-6 ORIGINAL PAPER Mobilization for HIV Voluntary Counseling and Testing Services in Vietnam: Clients’ Risk Behaviors, Attitudes and Willingness to Pay Long Hoang Nguyen1,3 • Bach Xuan Tran1,2 • Nhung Phuong Nguyen5 Huong Thu Thi Phan4 • Trang Thu Bui4 • Carl A Latkin2 • Published online: 12 September 2015 Ó Springer Science+Business Media New York 2015 Abstract A multi-site survey was conducted on a sample of 365 clients to assess their willingness to pay for HIV voluntary counseling and testing (VCT) services in Ha Noi and Nam Dinh province, two epicenters of Vietnam By using contingent valuation technique, the results showed that most of respondents (95.1 %) were willing to pay averagely 155 (95 % CI 132–177) thousands Vietnam Dong (*US $7.75, 2013) for a VCT service Clients who were female, had middle income level, and current opioid users were willing to pay less; meanwhile clients who had university level of education were willing to pay more for a VCT service The results highlighted the high rate of willingness to pay for the service at a high amount by VCT clients These findings contribute to the implementation of co-payment scheme for VCT services toward the financial sustainability of HIV/AIDS programs in Vietnam Keywords HIV testing Á Willingness to pay Á Contingent valuation Á Vietnam Long Hoang Nguyen and Bach Xuan Tran have equally contributed & Bach Xuan Tran bach@jhu.edu Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA School of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam Hanoi University of Pharmacy, Hanoi, Vietnam 123 Introduction The HIV epidemic in Vietnam is among those with the fastest growth in Asia [1] HIV infection is primarily driven by high-risk populations in the country (i.e., female sex workers, injecting drug users, men who have sex with men, and sexual intimate partners of drug users [2–6] Approximately 225,000 people were reported to have contracted HIV [7], but this rate was underestimated due to the fact that many people are unaware of their HIV-positive status [6] In such cases, widespread scale-up of HIV voluntary counseling and testing services (VCT) is critical to limit the transmission of HIV VCT has been recognized as a cost-effective part of the overall control strategy of the HIV/AIDS epidemic [8–10] VCT supports an individual to make an informed choice about being tested for HIV through counseling [11] A VCT procedure consists of components: (1) Pre-test counseling; (2) HIV testing; (3) Post-test counseling; and (4) Follow-up counseling [12] Counseling reduce possibilities of HIV infection and transmission through interpreting test results and initiating changes of risk behaviors, Furthermore, service users are provided referrals to additional care, such as preventive, psychosocial, and other essential services [11] VCT is also considered as an entry point for other HIV/AIDS preventive and treatment including the prevention of HIV transmission from mother to child [11, 13] VCT may lead to a decrease of risk behaviors among HIV-positive individuals, such as unprotected sex [14, 15] In addition, it enables early antiretroviral treatment, therefore improves health status and quality of life of people living with HIV/AIDS (PLWHA) VCT service has been used widely in Vietnam through supports of international donors Currently, there are 485 AIDS Behav (2016) 20:848–858 VCT sites in 63 provinces nationwide [16] However, there are small proportions of high-risk populations undergoing HIV testing (e.g., 15–32.7 % of female sex workers [17, 18], 36 % of men who have sex with men [19] ) Therefore, expanding HIV testing service coverage to high-risk populations is a high-priority task of the National HIV/AIDS Strategic Plan in Vietnam in the period of 2020–2030 [20] The Vietnamese government is currently confronting the challenge of ensuring the financial sustainability of HIV/AIDS programs (including VCT) According to the projection for the period 2011–2015, the total cost of HIV services will increase by 60 %, to approximately US $150 million However, internal sources can subsidize only 6–12 % of the total cost [21] In order to reduce the deficit, the Vietnamese Ministry of Health has identified potential strategies, such as decreasing cost, improving efficiency, mobilizing resources [22], and encouraging users’ co-payments [22] Accordingly, information about willingness to pay (WTP) of clients for VCT will help the government identify appropriate financial allocations to ensure sustainability of HIV/ AIDS intervention services WTP is defined as the largest sum of money that a customer is amenable to pay in order to obtain a certain good or service The measurement of willingness to pay could be derived by revealed- or stated- preference approaches In evaluation of health care intervention, a stated-preference method that has been widely used is contingent valuation (CV) [23] CV is defined as a survey-based and hypothetical elicitation technique to estimate WTP values of customers for a service they receive through their evaluation of hypothetical scenarios [23] Currently, there has been a little research on WTP for VCT [24, 25] This paper aimed to determine the WTP for VCT and identify the WTP-related factors among Vietnamese clients through a multi-site survey Results from the study may inform social mobilization policy for sustainability of HIV/AIDS programs Methods Study Setting and Sampling This study was a part of ‘‘HIV Service User Survey 2013’’ (HSUS 2013), which evaluated the effects of integrated HIV-related service delivery models on health and economic outcome of PLWHA in Vietnam The cross-sectional study was conducted in Hanoi and Nam Dinh from January to August 2013 These two cities are among the areas with the largest HIV infection burden in northern 849 region in Vietnam, with 20,762 and 3781 PLWHA in Hanoi and Nam Dinh, respectively [16] VCT clinics were purposively selected based on several following criteria: (1) providing VCT services; (2) comprising provincial-; district- and commune-level; (3) implementing HIV-testing and consultation according to the official guideline of Vietnam Ministry of Health [26] and (4) representing for both urban and rural areas The list of all VCTs meet eligible criteria was prepared and we estimated that sites are needed to derive a sample of 400 clients We selected provincial and the only one commune VCT in the sample frame, and then randomly selected district- VCT sites Accordingly, six VCT facilities were selected four sites in Hanoi, including in provincial site (Hang Bai clinic), district sites (Dong Anh and Hoang Mai district health centers) and commune site(Truc Bach); two sites in Nam Dinh, including in provincial site (Nam Dinh HIV/AIDS control center) and district site (Xuan Truong district health center).The information of each clinic was described below: Name Level Location Other services Nam Dinh Provincial AIDS Center Provincial Nam Dinh Methadone Maintenance Xuan Truong District Health Center District Nam Dinh ART/MMT, General Health Hang Bai Clinic Provincial Hanoi General Health Dong Anh District Health Center District Hanoi ART, General Health Hoang Mai District Health Center District Hanoi ART, General Health Truc Bach Commune Health Station Commune Hanoi General Health The VCT clients were introduced about the study at the waiting room by a well-trained interviewer This could be either a master student at Hanoi Medical University or a counselor at the VCT site The inclusion criteria included: (1) visiting clinics during the study period; (2) being age from 18 years or above; and (3) having capacity and agreement to answer the questionnaires The VCT clinics were organized following a national guideline so that they are similar in terms of service, procedure and facility Clients may decide to take VCT in any site if they would like to During the period of the study, it is estimated that each site had about 10–50 clients per month; therefore, we set a months as a duration for data collection We approached and invited all clients who visited the selected VCT for the study Before interviewing, we explained the 123 850 AIDS Behav (2016) 20:848–858 purpose of this study and obtained informed consents from eligible subjects The selected individuals were invited to designated counseling rooms for an interview Respondents included both those clients who first come to take the services or those who returned for taking the results To examine if the test results would influence patients’ preference, we included the HIV-status of clients in the statistical analysis Socioeconomic Status Measures and Instruments Health-Related Quality of Life A structured questionnaire was developed to collect the data of interest Due to the lack of data about WTP for VCT, we developed the conceptual framework through a literature review to identify the determinants of WTP for VCT services in previous studies For example, a study of Ozochukwu underlined the positive role of socio-economic characteristics (age, gender, education, etc.) and VCT toward-knowledge and attitude in WTP for VCT Meanwhile, some studies suggested both positive and negative relations among socio-economic status, risk behaviors (sexual activities, condom use, drug use, etc.), health status and VCT service utilization [18, 27, 28] The conceptual framework was figured out in Fig The variables of interest were listed below: Health-related quality of life was measured by using EQ5D-5L instrument, which was validated elsewhere [29] This instrument assessed five dimensions including mobility, self-care, usual activities, pain/discomfort and anxiety/depression [30], with five levels of response: no problems, slight problems, moderate problems, severe problems, and extreme problems Fig Conceptual framework to determine the associated factors with WTP for VCT The socio-economic factors included age, gender, marital status, educational level, employment, and income Monthly household income per capita was calculated through all household members’ incomes Then, this income was categorized into five quintiles as ‘‘poorest’’, ‘‘poor’’, ‘‘middle’’, ‘‘rich’’ and ‘‘richest’’ Sexual Behaviors Sexual behaviors, such as number and type of partners, condom use with last sex, and percentage of condom use in the last 12 months, were investigated Non-condom use with last sex was identified when the respondent did not SocioKnowledge and economic Health status Risk behaviors attitude status - Income - Health-related - Knowing - Unsafe sex, - Expenditure quality of life relatives with condom use, - Age - Mental health HIV-positive sexual contact - Gender - Physical - Benefits and with sex - Education health roles of taking workers - Marital status VCT - Alcohol use - Employment - Importance of - Drug use: VCT history, - Referral for concurrent relatives Willingness to pay for VCT 123 AIDS Behav (2016) 20:848–858 use condom in the last sex (i.e., primary partners, casual partners, and sex workers) Opiate Drug Use Behaviors Information about illicit opioid (comprising heroin and other opiates) use included: lifetime opiate drug use, lifetime opiate drug injection, and current opiate drug use Current opiate drug user was defined as a person currently used illicit opioid at the time they took HIV testing and counseling VCT Use and Referral In this study, metrics about total times of using VCT until the interview, information about a person who referred respondents to take initial VCT used and whether or not respondents referred their partners/relatives to VCT services were collected In addition, whether VCT clients were willing to be voluntary peer instructors was also considered in the study To figure out the HIV/AIDS status of clients and their family members, some approaches were utilized For people went to clinics to take test and consultation, we asked questions about HIV status of their family members, provided codes to them and then the clients used their codes to have HIV test This step would help to ensure the confidential of clients When the test results were available, we matched the codes for the correspond questionnaires Otherwise, for people went to clinics to take test results, we only asked them to report their HIV status without providing codes Willingness to Pay for VCT To support respondents in evaluating their WTP for VCT, a scenario, containing general information about several 851 aspects of VCT in Vietnam, was provided to ensure that patients had sufficient background knowledge about VCT First, the interviewers reviewed the transmission pathways of HIV and the benefit of VCT (e.g., knowing HIV/AIDS status, preventing risk of infection) [11] Then, they summarized the financial problem related to VCT in the future, and the national plan in confronting the issues and scalingup the coverage of VCT services [20] Specifically, surveyors explained that although VCT was current free-ofcharge due to the donation of international sources, that funding will be decreased and that co-payment from VCT clients may be essential to maintain the VCT services For patients or clients who already used VCT services, they were asked to imagine that they would have a need to utilize VCT services in the future This assumption helped the participants selecting their options easier To elicit WTP for VCT, double-bounded dichotomouschoice questions combined with an open-ended question were used in the study To select an initial price, we based on previous studies about cost per client for VCT in Vietnam A study showed that the cost per client was from US $28.4 to US $38.9 in 2007 [31], while another study reported a much lower cost of US $7.6 in 2012 [31, 32] The difference may explain by higher number of clients per setting in the latter study compared to the former one [32] To adapt the results of those studies and adjust to the number of VCT clients per site, twenty US dollars (20,000 VND = US $1, 2013 exchange rate) were selected to be an initial price in the current study After understanding the scenario described above, each patient was asked a number of Yes/No questions about their willingness to pay specific prices (see bidding process in Fig 2) First, they were asked to whether they were willing to pay US $20 for VCT service Depending on their choice, interviewers presented two other bids: the double bid for respondents answering ‘‘Yes’’; and the half bid for respondents saying ‘‘No’’ The question was repeated until Fig Bidding process of the contingent valuation method N an unwillingness to pay; Y a willingness to pay 123 852 the last bid was equal to four times or one-eighth of the initial price Finally, the respondents were asked an openended question ‘‘What is the maximum price you would be willing to pay for VCT service?’’ Statistical Analysis STATA version 12.0 (Stata Corp LP, College Station, United States of America) was used to analyze the data Statistical significance set at p \ 0.05 To examine differences in various characteristics among participants across three healthcare system levels (provincial, district and commune), ANOVA, Kruskal–wallis and v2 tests were used Data about WTP was mixed between censored and uncensored data due to the combination of double-bounded and open-ended questions An average amount of WTP for VCT in different patient groups was estimated by using an interval model [33] Multivariate interval regression was used to determine factors associated with the amount of WTP for VCT services In the model, the amount of WTP was an outcome variable, while factors such as socioeconomic, health status (EQ-5D), risk behaviors, attitude, and uses of VCT services were independent variables Stepwise backward strategies based on log-likelihood ratio test were used to construct the reduced model, in which p values [0.2 was the threshold for exclusion Ethical Approval The research was approved by the Medical Ethical Committee of the Authority for HIV/AIDS Control at the Vietnamese Ministry of Health Results A total of 365 VCT clients were recruited to the study, including 38.1 % at provincial clinics and 32.6 % at district ones Of these, 32.6 % were female, 58.6 % aged under 35, 64.1 % lived with their spouse, and more than 70 % of the respondents completing high school or above Almost all of them were workers/farmers or self-employed (Table 1) Self-reported health-related quality of life of clients is shown in Table Most of the respondents reported problems in Anxiety/Depression (68.2 %) Approximately onethird of subjects reported suffering issues in Mobility and Pain/Discomfort Meanwhile, only 8.2 % clients reported having problems in Self-care Regarding risky sexual behaviors, 46.6 % of respondents had one partner in the last twelve months, and 39.2 % reported more than one partner Among those who were sexually active, the proportion of the participants not to use 123 AIDS Behav (2016) 20:848–858 condom in the last sex with their primary partners was the highest compared with casual sex partners or sex workers However, the frequency of using condom with main partners (spouse/beloved) was the highest (mean = 37.2 times out of 100; SD = 32.3) In addition, one out of ten had a history of illicit drug use, 6.9 % reported a history of drug injection, and 4.1 % reported currently use drugs (Table 3) Table shows attitude toward and uses of VCT amongst respondents The average frequency of VCT uses was 1.12, higher at the provincial level than at the commune level Peers and media were the most frequent referrers of the first VCT use amongst clients (25.6 and 26.1 %, respectively), while parents/relatives were the least frequent HIV prevalence was low in respondents (4.7 %) but high in their family members (64.7 %) More than half of the clients would refer to their partners or relatives to VCT services (60.3 and 51.5 %, correspondingly) However, only one-fourth of people would become voluntary peer instructors The preference and WTP for VCT services is described in Table Overall, most of the respondents were willing to pay for VCT (95.1 %) The mean amount they were willing to pay was 155 thousand Vietnam Dong per utilization (95 % CI 132–177 thousands Vietnam Dong), equivalent to US $7.75 in 2013, and varied across groups Female clients and those clients utilizing VCT at the district or rural clinics were willing to pay less than other client groups Table shows the findings from reduced multivariate regression to determine factors related with the amount of WTP for VCT service Clients were willing to pay a smaller amount for VCT service if they were female, current drug users, and belonged to middle income Meanwhile, respondents completing university education were willing to pay a higher price for VCT compared to those being illiterate Discussion This study indicated the high prevalence of mental and physical health problems; and sexual risky and illicit drug use behaviors amongst VCT clients Most people using VCT services reported anxiety/depression symptoms This may be due to the fact that when someone went to VCT facilities, they were worried about their HIV status In many developing countries, people who are infected with HIV have to confront not only the decline of health status, but also the serious stigma and discrimination of the communities [34] Moreover, the prevalence of sexual risk behaviors among VCT clients was still high, while the AIDS Behav (2016) 20:848–858 Table Characteristics of VCT clients by level of services administration 853 Characteristics Province District Commune N % N % 49 35.3 47 39.5 21 8.5 18 15.1 N Total p value* % N % 23 21.5 119 32.6 0.016 16 15.0 39 10.7 0.13 Gender Female Age 18–\25 25–\30 27 19.4 20 16.8 29 27.1 76 20.8 30–\35 45 32.4 26 21.9 28 26.2 99 27.1 35–\40 23 16.6 26 21.9 16 15.0 65 17.8 40–\45 16 11.5 16 13.5 11 10.3 43 11.8 C45 18 13.0 18 15.1 6.5 43 11.8 25 94 18.0 67.6 27 78 22.7 65.6 31 62 29.0 57.9 83 234 22.7 64.1 Marital status Single Live with spouse Live with partner 4.3 2.5 4.7 14 3.8 Divorced 6.5 5.9 2.8 19 5.2 Widow 3.6 3.4 6.0 5.61 15 4.1 0.00 Educational attainment Illiterate 0.7 – – 0.9 0.6 Elementary – – 12 10.1 4.7 17 4.7 Secondary 25 18.0 40 33.6 19 17.8 84 23.0 High 44 31.7 39 32.8 49 45.8 132 36.2 Vocational 49 35.3 22 18.5 18 16.8 89 24.4 University 20 14.4 5.0 15 14.0 41 11.2 \0.001 Employment Unemployed 11 7.9 13 10.9 4.7 29 8.0 Self-employed 46 33.1 52 43.7 40 37.4 138 37.8 White collars 43 30.9 10 8.4 24 22.4 77 21.1 Workers, farmers Students 27 19.4 4.3 34 28.6 0.8 20 10 18.7 9.4 81 17 22.2 4.7 Other jobs 4.3 7.6 7.5 23 6.3 Cult of ancestors 96 69.1 96 80.7 101 94.4 293 80.3 Buddhism 34 24.5 16 13.5 0.0 50 13.7 Catholic 6.5 5.9 4.7 21 5.8 Protestant 0.0 0.0 0.9 0.3 0.07 Religion \0.001 *Using Chi squared test proportion of people reported using illicit drugs was low This finding corresponds the changing pattern of HIV transmission—from injection drug transmission to sexual transmission in Vietnam [16] While investigating the attitudes towards VCT, the study found that peers and media were the most popular factors that facilitated initial VCT visit of clients Furthermore, high rates of clients had already referred the service to their relatives This finding was similar to other studies conducted in Ethiopia [35, 36] and Nigeria [37], indicating that those channels are potential approaches to expand the benefits of VCT service to population In addition, most respondents expressed a WTP for VCT services The observations indicated the noteworthy agreements of clients about WTP for VCT services, suggesting that they already perceived benefits of VCT and their responsibility of co-payment The mean amount of WTP for VCT in this study was US $7.75 The result was much lower than the cost per client in the study of Hoang et al in 2007 (in facility-based VCT: US $30.3; in free-standin g VCT facility: US $38.9) [31], but approximately equal to the survey of Nguyen et al (with US $7.6) in 2012 [32] This amount of WTP accounted for 0.41 % GDP per capita in 123 854 AIDS Behav (2016) 20:848–858 Table Health-related quality of life of VCT Clients Health status EQ5D profile Province District Commune Total N N N N % % % p value* % Mobility Have problems No problems 21 15.1 39 32.8 35 32.7 95 26.0 118 84.9 80 67.2 72 67.3 270 74.0 \0.05 Self-care Have problems No problems 3.6 25 21.0 – 134 96.4 94 79.0 107 – 30 8.2 100.0 335 91.8 \0.001 Usual activities Have problems No problems \0.001 10 7.2 37 31.1 1.9 49 13.4 129 92.8 82 68.9 105 98.1 316 86.6 54 85 38.9 61.2 46 73 38.7 61.3 31 76 29.0 71.0 131 234 35.9 64.1 0.21 100 71.9 52 43.7 97 90.7 249 68.2 \0.001 39 28.1 67 56.3 10 9.4 116 31.8 Pain/discomfort Have problems No problems Anxiety/depression Have problems No problems *Using Chi squared test Table Risk behaviors of VCT clients Province Ever had sex District N % N % 136 97.84 105 88.24 Commune Total p value* N % N % 106 99.07 347 95.07 0.14 \0.001 Number of sex partners (in the last 12 months) None 10 7.19 38 31.93 3.74 52 14.25 One sex partners 66 47.48 67 56.3 37 34.58 170 46.58 2–3 sex partners 48 34.53 5.88 45 42.06 100 27.4 [4 sex partners 15 10.79 5.88 21 19.63 43 11.78 124 89.21 84 70.59 98 91.59 306 83.84 \0.001 41 28 29.5 20.14 16 1.68 13.45 21 36 19.63 33.64 64 80 17.53 21.92 \0.001 \0.001 62.65 Type of sex partner Primary partners Casual sex partners Sex workers Condom use with last sex With primary sex partners (n = 305) 62 50 52 55 56.12 169 55.41 0.20 With casual sex partners (n = 60) 14 36.84 – – 42.86 23 38.33 0.66 30.77 16 100.0 11 32.35 35 46.05 \0.001 With sex workers (n = 76) Mean SD Mean SD Mean SD Mean SD Percentage of condom use (in the last 12 months) With primary sex partners With casual sex partners 54.2 21.5 39.2 38.1 31.4 – 42.1 – 16.1 65.3 35.0 4.6 37.2 11.8 32.3 28.1 \0.001 \0.001 With sex workers 16.1 35.0 4.4 17.4 65.5 32.6 23.9 35.1 \0.001 N % N % N Ever drug use 19.0 13.7 12.0 10.1 7.0 Ever inject drug 15.0 10.8 7.0 5.9 3.0 Current drug use 9.0 47.4 4.0 33.3 2.0 *Using Chi squared test and ANOVA 123 % N % 6.5 38.0 10.4 2.8 25.0 6.9 0.04 28.6 15.0 4.1 0.60 0.19 AIDS Behav (2016) 20:848–858 855 Table Attitudes and Uses of VCT services VCT service utilization (total times) Province District Mean 95 % CI Mean 1.45 1.03 1.07 N Referrer of the first VCT used Spouse 1.88 % Commune Total 95 % CI Mean 95 % CI Mean 95 % CI 0.77 0.75 0.60 1.12 0.93 N % N 1.37 % 0.89 N p value* 1.31 \0.05 % p value* \0.05 10 12.7 23 37.7 4.5 36 17.4 Peers 14 17.7 9.8 33 49.3 53 25.6 Health workers 10 12.7 14.8 6.0 23 11.1 Media 25 31.7 11.5 22 32.8 54 26.1 Self-motivation 16 20.3 11 18.0 6.0 31 15.0 Parents/relatives 5.1 8.2 1.5 10 4.8 10 7.2 1.7 4.7 17 4.7 HIV status (positive) Individual 0.16 Family members 107 77.0 69 58.0 60 56.1 236 64.7 \0.05 Spouse/partners 4.3 32 26.9 2.8 41 11.2 \0.001 Parents 0.0 0.8 0.0 0.3 0.35 Brother/sister 2.2 4.2 0.0 2.2 0.1 Other relatives 11 7.9 1.6 0.0 13 3.5 \0.05 86 61.9 71 59.7 63 58.9 220 60.3 0.88 Refer partners to HIV testing services Refer other relatives to HIV testing services 75 54.0 58 48.7 55 51.4 188 51.5 0.7 Volunteer to be a peer instructor 28 20.1 29 24.4 38 35.5 95 26.0 \0.05 *Using Chi squared test and ANOVA Table Willingness to pay for VCT service Willing to pay Amount of WTP (1000 Vietnam Donga) No % Mean (95 % CI) 365 347 95.1 155 132 177 Male 246 233 94.7 169 139 198 Female 119 114 95.8 125 91 159 Provincial 139 137 98.6 192 153 232 District 119 106 89.1 97 69 125 Commune Area 107 104 97.2 169 122 216 Variable Overall N Sex Level a Urban 266 261 98.1 182 153 210 Rural 99 86 86.9 81 53 109 USD = 20,000 Vietnam Dong Vietnam in 2013 (US $1910, according to the statistic of World Bank) [38], making this amount being acceptable for the clients to pay However, a study conducted in Nigeria indicated that the mean amount of WTP was much lower (US $3.2) [24], despite of a higher GDP per capita in Nigeria compared to Vietnam Additional research conducted in Kenya estimated another amount was US $2 [25] This can be explained by various factors First, the cost to 123 856 Table Factors associated with willingness to pay for VCT services among Vietnamese clients AIDS Behav (2016) 20:848–858 Characteristic Coef p 95 % CI Employment Unemployed (ref) Self-employed 60.43 0.11 -13.65 134.51 White collars 58.27 0.19 -29.21 145.75 -97.43 0.02 -177.19 -17.66 -122.88 0.19 -306.64 60.88 -164.48 0.12 -368.75 39.80 129.35 0.11 -27.63 286.34 -103.70 \0.01 -174.14 -33.27 117.89 0.02 17.73 218.05 -140.78 0.03 -269.35 -12.21 193.74 \0.01 133.51 253.97 Income per capita Poorest (ref) Middle Condom use with Spouse/Partner Yes (ref) Unknown Brother/Sister have HIV positive Yes (ref) No Referrer of the first VCT used Spouse (ref) Parents/Relatives Gender (Female vs Male) Male (ref) Female Education Illiterate (ref) University Current drug use No (ref) Yes Constant operate VCT centers in those areas was lower than in Vietnam [25, 31] Second, respondents engaged in highrisk behaviors in concentrated epidemics like Vietnam may perceive importance and necessity of VCT than those in generalized epidemics [39, 40] Finally, in reference settings, respondents believed that these services should have been provided without charge [24] This study also identified differences of mean WTP amounts in various health service system levels While the clients were inclined to spend approximately US $10 at the provincial and commune clinics, US $5 was the maximum amount a customer was amenable to sacrifice at the district levels It might reflect that the clients were not satisfied with the quality of services (e.g., counseling procedure, clinics’ facilities and/or the ability of health staffs, etc.) at those centers and they did not want to pay more Additionally, the finding that male clients and people with university education were willing to pay more than the others is consistent with a previous study [24] Nonetheless, the respondents with middle income per capita were willing to pay less than the poorest group 123 Normally, people with higher income are willing to pay more [41, 42] Notably, when analyzing the data more deeply for the frequency of having HIV-test according to levels of income (data not shown), we observed the higher rate of people not taking HIV-test before the interview in the lowest income quintile compared to that in other levels When using contingent valuation approach, this phenomenon had to be concerned as a lack of familiarity in VCT service utilization may lead to hypothetical bias Previous literature emphasized the role of familiarity characteristic that people having insufficient experience for unfamiliar goods tended to overestimate their WTP [43] The result also found that current drug users were willing to pay less than others Some current drug users may avoid using health care services including HIV testing Besides, a previous study reported that monthly spend of drug users for opiates were US $540, which were five times higher than their average income per capita [41] This expenditure places economic burden on households, which may affect the WTP of respondents AIDS Behav (2016) 20:848–858 The study has several implications First, the high prevalence of sexual-risk behaviors (e.g., multiple partners, inconsistent condom use) implied the need for counseling and education about the role of safe sex in preventing HIV infection Second, clients themselves and media (television, radio, etc.) were demonstrated as potential channels to disseminate benefits of VCT service to this vulnerable population Third, the study indicated the possibility of copayment implementation to ensure the sustainability of HIV/AIDS programs regarding the proportion of respondents accepting to pay for VCT and their mean WTP amount [32] Finally, since the WTP of high-risk populations such as female [5] or current drug users was observed to be lower than other subjects, a subsidy or incentives for those populations should be taken into consideration Apart from investigating WTP, some suggestions are drawn to reduce the cost and to address the financial sustainability of VCT services The government should set up different VCT delivery models in appropriate locations, such as stand-alone VCT units were placed in the areas with a high prevalence of HIV/AIDS while integration facilities were established in low-risk areas [41, 44] It is noteworthy that freestanding VCT facilities required much more resources than integration model [31] The study in Kenya showed an amount of US $8 per client may be reduced if general health staffs could play a role as HIV counselor [25] Health insurance is also a considerable approach to tackle the issue However, ensuring the equity and financial balance for other chronic diseases are great challenges [45] The strengths of this study lie in various settings in two Vietnamese epicenters Clients were provided basic background of VCT and the current situation of financial problem for VCT before asking the WTP, thus their responses may reflect their true opinions about the issue, which lead to reliable results Additionally, contingent valuation method and multivariate interval regression were used appropriately to improve the estimation of WTP by mixing censored and uncensored data [33] However, the research has several limitations Firstly, the generalization of our results was limited due to the convenience sampling We acknowledge the limitation that we include only provinces with a small number of clients in this study, and would like to notice readers to be cautious in the application of our research findings Secondly, a small sample size was used in the study, which may result in the deficiency of statistical power Finally, contingent valuation is a subject measure, which may lead to the uncontrolled bias For example, people regularly respond to the bids that are benefit for them [46] To diminish this issue, the purpose of study as well as the confidentiality of clients was clearly explained before the interview 857 In conclusion, the rates of WTP and the amount that Vietnamese clients were willing to pay were higher, compared to other studies The findings are partly contributed to the implementation of co-payment policy toward the sustainability of HIV/AIDS interventions in Vietnam Acknowledgments Dr Bach Tran received the joint fellowship of the International AIDS Society and the National Institute on Drug Abuse that encourages HIV and drug use research The study was funded by Vietnam Authority of HIV/AIDS Control We would also like to thank all research managers, staffs and 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Onwujekwe O, Sibeudu T Voluntary counseling and testing (VCT) for HIV/ AIDS: a study of the knowledge, awareness and willingness to pay for VCT among students in tertiary institutions in Enugu State Nigeria... of voluntary HIV counseling and testing (VCT) guidelines, (2007) 27 Wringe A, Isingo R, Urassa M, Maiseli G, Manyalla R, Changalucha J, et al Uptake of HIV voluntary counselling and testing services. .. they took HIV testing and counseling VCT Use and Referral In this study, metrics about total times of using VCT until the interview, information about a person who referred respondents to take initial