Knowledge and attitude of people towards voluntary counseling and testing for hiv
Background
Voluntary counseling and testing (VCT) is one of the many different strategies stipulated in the policy and strategy documents, for the prevention and control activities that are planned to be carried out and currently undergoing at the national level ( MOH, 1998). The role of voluntary counseling and testing can play on HIV/AIDS prevention and control is said to be multifaceted. Many indicated that VCT can be considered as entry point to prevention and care, medical care, for preventing mother to child transmission of HIV infection (PMCTC) interventions, for ongoing emotional and spiritual care and social support (UNAIDS, 2000). Hence, the need for expansion of voluntary counseling and testing service and stimulating its utilization is outlined as a priority intervention area and as an entry point for HIV prevention, through creating more personal awareness and care (NAC, 2001).
 In view of the widely acclaimed and important contribution, voluntary counseling and testing can have in the prevention and control of HIV/AIDS, and the observed growing demand for the service (NAC, 2000), HIV testing may have far reaching implications and consequences for the person being tested. Although there are important benefits to knowing one's HIV status, HIV infection in many communities, is a stigmatizing condition and this can lead to negative outcomes for people following testing. Stigma may actively prevent people accessing care, gaining support, and preventing onward transmission. Many people are afraid to seek HIV service, because they fear stigma and discrimination from their families and communities(UNAIDS, 2000). Furthermore, fear and stigmatization associated with HIV testing can minimize public acceptance of the voluntary counseling and testing, dwarfing the role the service can play in prevention and control initiatives.
 Apart from the social implication the HIV testing could have and the weakness observed in the existing service delivery points (NACS, 2000).  Findings of the few studies conducted in Ethiopia revealed that, other factors like lack of awareness about the mode of transmission of the disease (HIV/AIDS), lack of perceived benefit for having the HIV test, limitation related with the economic and physical access to the service etc, are some of the factors that can contribute for the low utilization of the already available services (Michael, 2001).However, none of the very few studies conducted so far in the country tried to give a comprehensive overview about the attitude and knowledge of people towards VCT of which is a widely acclaimed but underutilized service.
 Voluntary HIV counseling and testing (VCT) is then a process by which an individual undergoes counseling enabling him/her to make an informed choice about being tested for HIV. This process is also aimed at helping them to cope with stress and to make personal decisions related to HIV/AIDS (MOH, 2002). It means voluntary counseling and testing is important for the following reasons.
Hence, this study will be done with the main purpose of filling the knowledge gap in the knowledge and attitude of people towards voluntary counseling and testing services in shashemene. Shashemene is located 250 km apart from Addis Ababa in the southern direction. Shashemene is one of the cities in 0romia region. The population living in this town is estimated to be 103,000. Shashemene is the commercial center and the joint place from four different directions: - Awassa from south, Addis Ababa from north, Arbaminch from west and Bale from east. This indicates that people come from different areas to the city. So there may be a high prevalence of HIV/AIDS in the area. Developing the awareness of people in this area towards VCT has great importance in reducing the transmission of HIV/AIDS. Therefore, this study asses the knowledge and attitude of people towards voluntary counseling and testing for HIV in Shashemene.
Statement of the problem
HIV/AIDS has become a prevalent disease and presents a global problem. Its impact if not controlled, will be profound and is considered to be highly distractive, fast spreading and expected to become the main causes of death among youth and middle age adults (highly productive and reproductive members of the society) (Assefa Befekadu, 1994).
 UNAIDS estimate that globally there were 64.8 million HIV infected people, among them 24.8 million were died due to the disease and the remaining 40 million living with HIV/AIDS. The African continent particularly the Sub-Saharan African countries are the most affected regions of the world (of the total HIV infected people 42.5 million live in sub-Saharan African countries) holding about 65.6 percent of all HIV infected individuals (UNAIDS, 2001).
 Ethiopia is one of these countries that are affected by this rapidly spreading Pandemic. The disease was known in the country in 1984 and now it is spreading at an alarming rate. The true number of AIDS cases since the beginning of the epidemic in Ethiopia is not known, but probably numbered about 400,000 (MOH, 2000). But after a while it is estimated that there are about 2.6 million people living with HIV/AIDS (2.4 million adults and 250,000 children). This number is expected to grow to more than three million by the year 2006     (MOH, 2000).In terms of absolute number of people infected, Ethiopia ranked third next to South Africa and Nigeria, which has about 4.2 and 2.7 million HIV, infected people respectively. As would be expected, HIV prevalence was low at its initial stage, in 1980's, and the increase has become rapid since the early 1990's.
 This research is designed with in an intention of finding answer to the following questions
 Objective and significance of the study
The objective of the study is to make assessment on knowledge and attitude of the target population and establish baseline information which will be the basis for future evaluation and intervention. More specifically the objectives are:
1. To asses the level of awareness of the target population on voluntary  counseling and testing.
2. To asses the knowledge and attitude of the community towards voluntary counseling and testing service.      Â
   3. To identify barriers related to voluntary counseling and testing and its use.                                                            Â
This study will contribute to the existing knowledge about this issue and is also expected to initiate researchers for further studies .Furthermore; it will give insight for interested social workers and other concerned bodies as to how to design their strategies to help people with the purpose of alleviating HIV/AIDS by expanding and applying voluntary counseling and testing program.
 Delimitation
This research will deal with the attitudes and knowledge of peoples towards VCT for HIV in shashemene, one of the zones in Ormia region. Of course shashemene is wider zone which consists of rural and urban kebeles. But this study will focus on the urban part of the town.
 To that end, the study will be conducted mainly with people living in the two kebeles of the city of shashemene.
 RESEARCH METHODS
Study method
 The approach selected for this study was survey method, since it gives the description of the statuesque of the phenomenon. This phenomenon in the study was to identify the attitude and knowledge of people towards voluntary counseling and tasting for HIV/AIDS. The use of this method aims at assessing an issue in a relatively manageable number of respondents (sample) takeout from large population.
 Sampling
Purposive sampling technique was used to select the population included in the study. The town of shashemene was selected as a target population for the study.
 As to the sampling design a probability sampling technique was used to carry out the questionnaire survey to generate data, which was used in this study. For the purpose of selecting representative kebeles, from the existing seven (7) kebeles in the town simple random sampling scheme was used, with this method two kebeles (six and four) were selected as a sample.
 Households in these kebeles were enumerated to know the available house holds in each kebeles. Code was given for each household in the two kebeles.  From all house holds in these kebeles only representative samples was selected using systematic random sampling scheme.
 In kebele four out of the total 1014 households 10 percent that are 101 eligible people in different age, education level, and religion filled the questionnaire. From kebele six out of the total 902 households 11 percent household's 99 eligible representatives were selected and filled the questionnaire. Therefore, the total numbers of respondents from each household were 200 samples. The respondents are designed to be equal number of males and females as one sample from a household.
 The rational for selecting samples male and female in different households were primarily to obtain diverse information from households. Secondly, comparison of women and men knowledge and attitude towards voluntary counseling and testing may vary because of variation in their level of education, occupation etc, they have than comparing women and men of the same households who share common experience in their life.
 Data gathering instruments
This study has employed quantitative data collection approach. A questionnaire was used as the main instrument. A structured questionnaire of three parts was administered. The first part of the questionnaire was intended to gather background information about the respondents. The second part of the questionnaire was intended together the knowledge base of the respondents regarding to voluntary counseling and testing. It comprised of 21 items, each item weighs one point. The third part was designed to asses the respondent's attitude towards voluntary counseling and testing issues. A three point Likert type attitude scale with a continuum "Agree", "Uncertain" and "disagree" was constructed.
 The scale consists of 25 items and the participants were asked to indicate their agreement with each statement using a three point attitude scale. The given scale value were 3 = agree, uncertain = 2 and disagree = 1 to the positively stated items.
 In the items that were negatively stated the scoring was reserved as, 1 = agree,   2=uncertain, and 3=disagree. The maximum possible score for the attitude scale would be seventy five (75).
 Pilot study
Before implementation, the questionnaire was translated in to Amharic and administered to those twenty four (24) households that live in kebele seven. To make the pilot study comprehensive the researcher includes educational level, age, sex and religion in to consideration.
 The kebele which is found far from the sample kebeles was purposely selected as the center for the pilot study so as to avoid test contamination. Coefficient Alpha and kuder–Richardson (KR–20) was used to see the internal consistency of attitude and knowledge items (scales) respectively. After calculating the internal consistency of the items, the reliability coefficient of attitude scale was .67 and the reliability coefficient of knowledge related items was .76 for the remaining quality items.
 Data collection procedure
Contact has been made with different persons who found in different responsibilities. This has been done for the purpose of getting information about the worda's HIV/AIDS condition and the relevance of voluntary counseling and testing. Moreover, the researcher found out whether related research was made or not in the worda.
 For the purpose of collecting information the researcher made strong relation with different associations of youths regarding to HIV/AIDS prevention and education. With having such relationship, the researcher has selected among those members for the purpose of enumeration and data collection. The activity of selection among those members of the association who have better knowledge and willingness to participate were made with the help of the coordinator of the association.
 The first step was training enumerators for the survey. Half day training on the survey questionnaire and how to approach households has been given for five enumerators. The field work was closely supervised by coordinators. The supervision was designed in such a way that as to closely monitor the data collection activities, facilitate the data enumeration process and ensure that the data collection takes place according to the instruction.
 After the questionnaire returned from the field, manual editing for completeness, accuracy & homogeneity and coding was undertaken on survey items to enhance data entry in to the computer. Information then entered and statistical tables were produced and analyzed by using SPSS-10 program.
DISCUSSION OF THE RESULT
 Knowledge of respondents towards HIV/AIDS
 Wider access to knowledge of HIVstatus would enable individuals to gain early access HIV specific care, treatment and support and access to intervention (WHO, 2002). It is vital that people protect themselves from HIV/AIDS. For this they should have adequate knowledge about the prevention and transmission mechanisms of the virus.
 To see the knowledge of respondents how to prevent HIV from spread, different prevention related questions were raised. Eighty eight percent from the total respondents replied that sexual intercourse is not the only way that HIV virus can transmit from HIV infected to uninfected persons. But common use of sharp materials, blood contamination and from mother to child during birth was other mechanisms. Most respondents know that condom is one way of preventing the transmission of HIV.
 People thought that HIV infected persons are thinner than those uninfected one's. Eighty nine percent of the respondents disprove this perception. To this end it is difficult to differentiate a person who has been infected by observing.
 There was a difference in the knowledge of respondents based on their sex. The difference was statistically significant. Females had greater knowledge on HIV/AIDS transmission and prevention mechanisms. But one-way ANOVA shows that there was no statistically significance difference among subjects based on their education level.
 knowledge of respondents to voluntary counseling and testing
 People need to have access to voluntary counseling and testing so they can find out about their HIV status and thus make the most of intervention for prevention and care. That is why voluntary counseling and testing is considered as an entry point to care and early detection service. Ninety eight percent of the respondents had the knowledge towards this idea. Meaning they know voluntary counseling and testing is an early detection service for HIV care program. Female and male groups had similar knowledge to this point. One-way ANOVA also show no significant difference among groups on their education level.
 Moreover, most respondents argued that adequate knowledge on voluntary counseling and testing reduce stigma and voluntary counseling and testing assist people to make informed decision to make HIV test.
 Voluntary counseling and testing is a key element in HIV prevention and care program. To this idea most respondents (90%) answered voluntary counseling and testing is a key element in HIV prevention and care program. Both female and male had the same level of information regarding this concept. There was a difference in the response of the respondents within different education level. Most illiterate persons (93.3%), primary educated people (82%), secondary educated persons (91.4%) and tertiary educated persons (89.7%) were responded voluntary counseling and testing is a key element to prevent HIV/AIDS.        One-way ANOVA shows there is statistically significant difference among subjects knowledge on their education level.
 Although voluntary counseling and testing is becoming increasingly available in developing and middle income countries, there is still great reluctance for many people to be tested. There are several contributing factors that must be addressed if voluntary counseling and testing has an important role in HIV prevention and care. In this regard, this study showed that HIV testing may have far reaching implications and consequences in the person being tested. Although there are important benefits of knowing HIV status, HIV infection in many countries is a stigmatizing condition and this can lead to negative out comes for people following testing. In this regard most respondents (71%) were responded that the up take of VCT service is very low due to denial and stigma. The remaining (29%) however, responded that they disagree with this concept. The analysis based on sex shows that 69% male and 73% female agree with idea raised. Meaning denial and stigma decreases the use of voluntary counseling and testing. This idea was also analyzed based on the respondents' education level. Illiterate persons (53.3%), primary educated persons (82%), secondary educated persons (73.4%) and tertiary educated persons (51.7%) respectively favor with stigma and discrimination hinder the use of voluntary counseling and testing service. To this concept the difference between male and female subjects are not significant. Moreover, the difference among groups in education level was also not significant.
 This analysis shows that illiterate and tertiary educated have the same knowledge base regarding stigma and discrimination as hindrance of taking voluntary counseling and testing service. Those primary educated individuals however, supported that denial and stigma are the most important factor that hinder voluntary counseling and testing service. Secondary educated people were in between the above groups. It showed that the level of awareness of respondents based on education level was unpatterned. It may be due to other factors.
 A key barrier to successful voluntary counseling and testing implementation is the inadequate access to voluntary counseling and testing service centers for the clients. Most (62.5%) of the respondents know that voluntary counseling and testing service is not available and unable to provide the adequate service, while only (37.5%) respondents replied that voluntary counseling and testing in their area gave adequate service. To this idea, there was a difference between male and female respondents. Most male respondents (72%) and (53%) female respondents answered that voluntary counseling and testing did not give adequate service in their area.
Educational level as a factor was also analyzed and hence illiterate respondents of 66.7% replied that the voluntary counseling and testing center found in their area would provide the adequate service. While those primary, secondary and tertiary levels educated respondents 67.8%, 67.2% and 55% of the respondents respectively replied that voluntary counseling and testing service in their area would not give the adequate service. The difference observed between female and male subjects and among groups at different education level is not significant.
 Lack of perceived benefit was also the other common barrier to voluntary counseling and testing. In poorer high prevalence areas, many people did not want voluntary counseling and testing service. Because they may afraid that little help will be available to them if they are infected and there fore, it is better not to know their serostatus. Therefore, people may perceive that voluntary counseling and testing is not much important for those who have low socio-economic status. Most (61.5%) respondents answered economic status couldn't be a barrier to the use of voluntary counseling and testing. But the remaining 38.5% respondents replied that economy become a barrier to the service or not.
 Analysis regarding to this idea was made based on sex and education level. There was no difference in the response of male and female respondents. Sixty one percent male and sixty two percent female respondents replied that socio-economic status affect the up take of voluntary counseling and testing. Those (86.5%) illiterate, (64.3%) primary, and 61% secondary level educated respondents replied that socio-economic status did not affect the use of voluntary counseling and testing while (54%) of the tertiary educated level respondents replied that the need to voluntary counseling and testing can be affected by socio-economic status. Analysis made on sex shows that there was no significance difference on their knowledge towards problems associated with voluntary counseling and testing. But there is significant difference among subjects in their education level as shown in the analysis table.
 Respondents' attitude to HIV/AIDS
As indicated in different research and findings voluntary counseling and testing is used to make people, aware of HIV/AIDS mode of transmission and prevention, function and problems associated with voluntary counseling and testing.
 Most respondents disagree with idea raised like sharing a meal, with HIV infected individuals and purchasing food items transfer HIV/AIDS. Respondents have good attitude towards the way how HIV/AIDS could be transmitted from infected to uninfected persons. This also can be gained through voluntary counseling and testing services.
 On the other hand the respondent's attitudes towards HIV prevention mechanisms, 64% of them agree that abstain from pre-marital sex is important and 46% of the respondents disagree with buying condom from shop or other place is embarrassing. This indicates that respondents have good attitude towards the use of HIV preventing mechanisms.
 In addition, 38.5% of the respondents were uncertain that whether HIV/AIDS is God's punishment or not. This indicate people may have a perception HIV/AIDS is a disease of sinners. It is a great problem which creates negative image in the mind of the respondents towards people, who are living with HIV/AIDS. Moreover, 86% of the respondents agree that free discussion on HIV/AIDS in the family is necessary.
 A t-test was used to see whether there is an attitude difference between male and female subjects with the above stated ideas. But the result did not show any significant different between groups towards the HIV/AIDS prevention and transmission mechanism.
 One-way ANVOA test was also used to see whether there is an attitude difference among groups of respondents. There was a statistically significant difference among groups. The difference show attitude towards HIV/AIDS decreases as education level increases except tertiary education level.
Attitude towards voluntary counseling and testing
Until recently, many people believed there were few benefits to knowing their serostatus. But Voluntary counseling and testing have various advantages to the needy. To this end voluntary counseling and testing service is used to adjust the life style of tested people, for psycho-emotional support, to make informed decision about HIV test, was raised. To these questions 62%, 59.5% and 72% of the respondents respectively agreed. From this we can understand that respondents' attitude towards voluntary counseling and testing service and its advantage is better the study community.
 Moreover, 44% of the respondents replied that voluntary counseling and testing is advantageous for infected women, who know their sero-status, to make informed choices about their reproductive lives. Further, voluntary counseling and testing provide information on the increased risk of opportunistic infections of sexually transmitted diseases.
 Further analysis on the advantage of voluntary counseling and testing was made based on sex and education level. The t-test analysis shows that there was no statistically significant difference between groups of male and female subjects in their attitude towards the advantages of voluntary counseling and testing services.
 One-way ANOVA was used to see whether there is an attitude difference among groups based their education level. The result showed that there was a significant difference among the groups in their attitude towards the advantages of voluntary counseling and testing services. That is as education level increases, the attitude towards the benefits of voluntary counseling and testing also increases.
 In addition to the above discussions, various questions related to problems associated with voluntary counseling and testing was raised and the result has been analyzed. Seventy four percent of the respondents disagree with People who went to voluntary counseling and testing have certain health problem. This indicates that even people had no problem of health they have to go to the service to check their HIV status or for other reason.
 Stigma and discrimination threatened people in order not to reveal test result. Here, forty seven percent of the respondents agree with the idea. Mostly people are not voluntary to go to voluntary counseling and testing, because they worry a lot about HIV test result. Forty seven percent of the respondents did not worry about their HIV test results. The two concepts above seem to have opposite response. People fear stigma and discrimination but they were not worry about the test result. This idea generates the concept that most people fear not the test result but the stigma and discrimination after the test, such attitude towards voluntary counseling and testing may reduce the use of the service.
 The other problem related to the attitude of respondents towards voluntary counseling and testing was fear of taking test result. But 45% of the respondents disagree while 40.5% the respondents agree. Seventy four percent of the respondents disagree that voluntary counseling and testing institutions in their area provide adequate service to clients. Thirty eight percent of the respondents hesitate to go to the voluntary counseling and testing service, because the service provided after test is not sufficient. This may hinder people from seeking voluntary counseling and testing services because of their economic problem. Fifty five percent of the respondents disagree that staying without test is better than being tested.
 With the attitude of people towards problems associated with voluntary counseling and testing further analysis was made on sex and education level. There was no statistically significant difference between male and female subjects. But one-way ANOVA showed that there is significant difference among groups at different education level. The analysis showed as the education level increases, there is a consistent decrease in the attitude of respondents to the problems associated with voluntary counseling and testing.
Suggestion
On the basis of the findings the researcher forwards the following suggestions.
 The result indicates that numerous numbers of people are aware of the advantage and problems associated with voluntary counseling and testing. But the practicability or using of voluntary counseling and testing was very low due to different factors that prohibit individuals in order not to use the service. Therefore, sensitivity program on the issue of voluntary counseling and testing and its physical, psychological and social benefit to people should be advocated by responsible bodies like government, non-government and civil societies
 More specifically, stigma and discrimination are the most significant factors which affect the use of voluntary counseling and testing. Therefore, exhaustive education, workshop for significant people like religious leaders, youth associations who are working in the area of HIV and other influencing bodies should be given to increase people's awareness on the negative consequences of stigma and discrimination.
 Institutions which give voluntary counseling and testing service should be available and equipped with necessary materials to give the adequate service needed by people. Moreover, these centers should have professionally trained counselors and "counselors" who are found in the institutions should get the appropriate training in order to treat clients empathetically.
 Eventually, further research should be conducted on the basis of other factors, since there could be different factors which were not included in this study.
Acknowledgement
 First and for most, I would like to thank my advisor R. Venkatalhm, professor at Addis Ababa University for his critical and constructive comments in the course of the study.
 I would like to extend my sincere gratitude to my wife W/ro Beletu Tesfaye, who performs all the data gathering activity. My special thank is to my friends Ato Wededegn Argaw and Ato Molla Alehegn for their moral and material support. Moreover, I would like to thank my brother Keya leul for his coordination and facilitation of data collection along with W/ro Beletu Tesfay.
 I would like to express my thanks to the kebele chair persons of the selected sites for their nreserved co-operations in providing the required information.
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Voluntary counseling and testing (VCT) is one of the many different strategies stipulated in the policy and strategy documents, for the prevention and control activities that are planned to be carried out and currently undergoing at the national level ( MOH, 1998). The role of voluntary counseling and testing can play on HIV/AIDS prevention and control is said to be multifaceted. Many indicated that VCT can be considered as entry point to prevention and care, medical care, for preventing mother to child transmission of HIV infection (PMCTC) interventions, for ongoing emotional and spiritual care and social support (UNAIDS, 2000). Hence, the need for expansion of voluntary counseling and testing service and stimulating its utilization is outlined as a priority intervention area and as an entry point for HIV prevention, through creating more personal awareness and care (NAC, 2001).
 In view of the widely acclaimed and important contribution, voluntary counseling and testing can have in the prevention and control of HIV/AIDS, and the observed growing demand for the service (NAC, 2000), HIV testing may have far reaching implications and consequences for the person being tested. Although there are important benefits to knowing one's HIV status, HIV infection in many communities, is a stigmatizing condition and this can lead to negative outcomes for people following testing. Stigma may actively prevent people accessing care, gaining support, and preventing onward transmission. Many people are afraid to seek HIV service, because they fear stigma and discrimination from their families and communities(UNAIDS, 2000). Furthermore, fear and stigmatization associated with HIV testing can minimize public acceptance of the voluntary counseling and testing, dwarfing the role the service can play in prevention and control initiatives.
 Apart from the social implication the HIV testing could have and the weakness observed in the existing service delivery points (NACS, 2000).  Findings of the few studies conducted in Ethiopia revealed that, other factors like lack of awareness about the mode of transmission of the disease (HIV/AIDS), lack of perceived benefit for having the HIV test, limitation related with the economic and physical access to the service etc, are some of the factors that can contribute for the low utilization of the already available services (Michael, 2001).However, none of the very few studies conducted so far in the country tried to give a comprehensive overview about the attitude and knowledge of people towards VCT of which is a widely acclaimed but underutilized service.
 Voluntary HIV counseling and testing (VCT) is then a process by which an individual undergoes counseling enabling him/her to make an informed choice about being tested for HIV. This process is also aimed at helping them to cope with stress and to make personal decisions related to HIV/AIDS (MOH, 2002). It means voluntary counseling and testing is important for the following reasons.
- To provide information on the mode of HIV transmission and prevention.
- To help those who wish to consider HIV testing make decision about whether or not to be tested and to provide support following the test.
- To provide information on the increased risk of HIV transmission associated with other sexually transmitted infections (STIs) and give referral for STI examination and treatment.
- To provide information on the increased risk of opportunistic infections including Tuber culosis (TB) associated with HIV infection.
- To provide referrals to HIV positive and high risk HIV negative persons for necessary medical, preventive and psycho-social services and home based care in the community.
Hence, this study will be done with the main purpose of filling the knowledge gap in the knowledge and attitude of people towards voluntary counseling and testing services in shashemene. Shashemene is located 250 km apart from Addis Ababa in the southern direction. Shashemene is one of the cities in 0romia region. The population living in this town is estimated to be 103,000. Shashemene is the commercial center and the joint place from four different directions: - Awassa from south, Addis Ababa from north, Arbaminch from west and Bale from east. This indicates that people come from different areas to the city. So there may be a high prevalence of HIV/AIDS in the area. Developing the awareness of people in this area towards VCT has great importance in reducing the transmission of HIV/AIDS. Therefore, this study asses the knowledge and attitude of people towards voluntary counseling and testing for HIV in Shashemene.
Statement of the problem
HIV/AIDS has become a prevalent disease and presents a global problem. Its impact if not controlled, will be profound and is considered to be highly distractive, fast spreading and expected to become the main causes of death among youth and middle age adults (highly productive and reproductive members of the society) (Assefa Befekadu, 1994).
 UNAIDS estimate that globally there were 64.8 million HIV infected people, among them 24.8 million were died due to the disease and the remaining 40 million living with HIV/AIDS. The African continent particularly the Sub-Saharan African countries are the most affected regions of the world (of the total HIV infected people 42.5 million live in sub-Saharan African countries) holding about 65.6 percent of all HIV infected individuals (UNAIDS, 2001).
 Ethiopia is one of these countries that are affected by this rapidly spreading Pandemic. The disease was known in the country in 1984 and now it is spreading at an alarming rate. The true number of AIDS cases since the beginning of the epidemic in Ethiopia is not known, but probably numbered about 400,000 (MOH, 2000). But after a while it is estimated that there are about 2.6 million people living with HIV/AIDS (2.4 million adults and 250,000 children). This number is expected to grow to more than three million by the year 2006     (MOH, 2000).In terms of absolute number of people infected, Ethiopia ranked third next to South Africa and Nigeria, which has about 4.2 and 2.7 million HIV, infected people respectively. As would be expected, HIV prevalence was low at its initial stage, in 1980's, and the increase has become rapid since the early 1990's.
 This research is designed with in an intention of finding answer to the following questions
- What is the level of community's awareness towards voluntary counseling and testing and its function?
- What are the community's knowledge and attitude towards voluntary counseling as HIV control mechanism?
- What are the obstacles that hinders in order not to use voluntary counseling and testing service?
 Objective and significance of the study
The objective of the study is to make assessment on knowledge and attitude of the target population and establish baseline information which will be the basis for future evaluation and intervention. More specifically the objectives are:
1. To asses the level of awareness of the target population on voluntary  counseling and testing.
2. To asses the knowledge and attitude of the community towards voluntary counseling and testing service.      Â
   3. To identify barriers related to voluntary counseling and testing and its use.                                                            Â
This study will contribute to the existing knowledge about this issue and is also expected to initiate researchers for further studies .Furthermore; it will give insight for interested social workers and other concerned bodies as to how to design their strategies to help people with the purpose of alleviating HIV/AIDS by expanding and applying voluntary counseling and testing program.
 Delimitation
This research will deal with the attitudes and knowledge of peoples towards VCT for HIV in shashemene, one of the zones in Ormia region. Of course shashemene is wider zone which consists of rural and urban kebeles. But this study will focus on the urban part of the town.
 To that end, the study will be conducted mainly with people living in the two kebeles of the city of shashemene.
 RESEARCH METHODS
Study method
 The approach selected for this study was survey method, since it gives the description of the statuesque of the phenomenon. This phenomenon in the study was to identify the attitude and knowledge of people towards voluntary counseling and tasting for HIV/AIDS. The use of this method aims at assessing an issue in a relatively manageable number of respondents (sample) takeout from large population.
 Sampling
Purposive sampling technique was used to select the population included in the study. The town of shashemene was selected as a target population for the study.
 As to the sampling design a probability sampling technique was used to carry out the questionnaire survey to generate data, which was used in this study. For the purpose of selecting representative kebeles, from the existing seven (7) kebeles in the town simple random sampling scheme was used, with this method two kebeles (six and four) were selected as a sample.
 Households in these kebeles were enumerated to know the available house holds in each kebeles. Code was given for each household in the two kebeles.  From all house holds in these kebeles only representative samples was selected using systematic random sampling scheme.
 In kebele four out of the total 1014 households 10 percent that are 101 eligible people in different age, education level, and religion filled the questionnaire. From kebele six out of the total 902 households 11 percent household's 99 eligible representatives were selected and filled the questionnaire. Therefore, the total numbers of respondents from each household were 200 samples. The respondents are designed to be equal number of males and females as one sample from a household.
 The rational for selecting samples male and female in different households were primarily to obtain diverse information from households. Secondly, comparison of women and men knowledge and attitude towards voluntary counseling and testing may vary because of variation in their level of education, occupation etc, they have than comparing women and men of the same households who share common experience in their life.
 Data gathering instruments
This study has employed quantitative data collection approach. A questionnaire was used as the main instrument. A structured questionnaire of three parts was administered. The first part of the questionnaire was intended to gather background information about the respondents. The second part of the questionnaire was intended together the knowledge base of the respondents regarding to voluntary counseling and testing. It comprised of 21 items, each item weighs one point. The third part was designed to asses the respondent's attitude towards voluntary counseling and testing issues. A three point Likert type attitude scale with a continuum "Agree", "Uncertain" and "disagree" was constructed.
 The scale consists of 25 items and the participants were asked to indicate their agreement with each statement using a three point attitude scale. The given scale value were 3 = agree, uncertain = 2 and disagree = 1 to the positively stated items.
 In the items that were negatively stated the scoring was reserved as, 1 = agree,   2=uncertain, and 3=disagree. The maximum possible score for the attitude scale would be seventy five (75).
 Pilot study
Before implementation, the questionnaire was translated in to Amharic and administered to those twenty four (24) households that live in kebele seven. To make the pilot study comprehensive the researcher includes educational level, age, sex and religion in to consideration.
 The kebele which is found far from the sample kebeles was purposely selected as the center for the pilot study so as to avoid test contamination. Coefficient Alpha and kuder–Richardson (KR–20) was used to see the internal consistency of attitude and knowledge items (scales) respectively. After calculating the internal consistency of the items, the reliability coefficient of attitude scale was .67 and the reliability coefficient of knowledge related items was .76 for the remaining quality items.
 Data collection procedure
Contact has been made with different persons who found in different responsibilities. This has been done for the purpose of getting information about the worda's HIV/AIDS condition and the relevance of voluntary counseling and testing. Moreover, the researcher found out whether related research was made or not in the worda.
 For the purpose of collecting information the researcher made strong relation with different associations of youths regarding to HIV/AIDS prevention and education. With having such relationship, the researcher has selected among those members for the purpose of enumeration and data collection. The activity of selection among those members of the association who have better knowledge and willingness to participate were made with the help of the coordinator of the association.
 The first step was training enumerators for the survey. Half day training on the survey questionnaire and how to approach households has been given for five enumerators. The field work was closely supervised by coordinators. The supervision was designed in such a way that as to closely monitor the data collection activities, facilitate the data enumeration process and ensure that the data collection takes place according to the instruction.
 After the questionnaire returned from the field, manual editing for completeness, accuracy & homogeneity and coding was undertaken on survey items to enhance data entry in to the computer. Information then entered and statistical tables were produced and analyzed by using SPSS-10 program.
DISCUSSION OF THE RESULT
 Knowledge of respondents towards HIV/AIDS
 Wider access to knowledge of HIVstatus would enable individuals to gain early access HIV specific care, treatment and support and access to intervention (WHO, 2002). It is vital that people protect themselves from HIV/AIDS. For this they should have adequate knowledge about the prevention and transmission mechanisms of the virus.
 To see the knowledge of respondents how to prevent HIV from spread, different prevention related questions were raised. Eighty eight percent from the total respondents replied that sexual intercourse is not the only way that HIV virus can transmit from HIV infected to uninfected persons. But common use of sharp materials, blood contamination and from mother to child during birth was other mechanisms. Most respondents know that condom is one way of preventing the transmission of HIV.
 People thought that HIV infected persons are thinner than those uninfected one's. Eighty nine percent of the respondents disprove this perception. To this end it is difficult to differentiate a person who has been infected by observing.
 There was a difference in the knowledge of respondents based on their sex. The difference was statistically significant. Females had greater knowledge on HIV/AIDS transmission and prevention mechanisms. But one-way ANOVA shows that there was no statistically significance difference among subjects based on their education level.
 knowledge of respondents to voluntary counseling and testing
 People need to have access to voluntary counseling and testing so they can find out about their HIV status and thus make the most of intervention for prevention and care. That is why voluntary counseling and testing is considered as an entry point to care and early detection service. Ninety eight percent of the respondents had the knowledge towards this idea. Meaning they know voluntary counseling and testing is an early detection service for HIV care program. Female and male groups had similar knowledge to this point. One-way ANOVA also show no significant difference among groups on their education level.
 Moreover, most respondents argued that adequate knowledge on voluntary counseling and testing reduce stigma and voluntary counseling and testing assist people to make informed decision to make HIV test.
 Voluntary counseling and testing is a key element in HIV prevention and care program. To this idea most respondents (90%) answered voluntary counseling and testing is a key element in HIV prevention and care program. Both female and male had the same level of information regarding this concept. There was a difference in the response of the respondents within different education level. Most illiterate persons (93.3%), primary educated people (82%), secondary educated persons (91.4%) and tertiary educated persons (89.7%) were responded voluntary counseling and testing is a key element to prevent HIV/AIDS.        One-way ANOVA shows there is statistically significant difference among subjects knowledge on their education level.
 Although voluntary counseling and testing is becoming increasingly available in developing and middle income countries, there is still great reluctance for many people to be tested. There are several contributing factors that must be addressed if voluntary counseling and testing has an important role in HIV prevention and care. In this regard, this study showed that HIV testing may have far reaching implications and consequences in the person being tested. Although there are important benefits of knowing HIV status, HIV infection in many countries is a stigmatizing condition and this can lead to negative out comes for people following testing. In this regard most respondents (71%) were responded that the up take of VCT service is very low due to denial and stigma. The remaining (29%) however, responded that they disagree with this concept. The analysis based on sex shows that 69% male and 73% female agree with idea raised. Meaning denial and stigma decreases the use of voluntary counseling and testing. This idea was also analyzed based on the respondents' education level. Illiterate persons (53.3%), primary educated persons (82%), secondary educated persons (73.4%) and tertiary educated persons (51.7%) respectively favor with stigma and discrimination hinder the use of voluntary counseling and testing service. To this concept the difference between male and female subjects are not significant. Moreover, the difference among groups in education level was also not significant.
 This analysis shows that illiterate and tertiary educated have the same knowledge base regarding stigma and discrimination as hindrance of taking voluntary counseling and testing service. Those primary educated individuals however, supported that denial and stigma are the most important factor that hinder voluntary counseling and testing service. Secondary educated people were in between the above groups. It showed that the level of awareness of respondents based on education level was unpatterned. It may be due to other factors.
 A key barrier to successful voluntary counseling and testing implementation is the inadequate access to voluntary counseling and testing service centers for the clients. Most (62.5%) of the respondents know that voluntary counseling and testing service is not available and unable to provide the adequate service, while only (37.5%) respondents replied that voluntary counseling and testing in their area gave adequate service. To this idea, there was a difference between male and female respondents. Most male respondents (72%) and (53%) female respondents answered that voluntary counseling and testing did not give adequate service in their area.
Educational level as a factor was also analyzed and hence illiterate respondents of 66.7% replied that the voluntary counseling and testing center found in their area would provide the adequate service. While those primary, secondary and tertiary levels educated respondents 67.8%, 67.2% and 55% of the respondents respectively replied that voluntary counseling and testing service in their area would not give the adequate service. The difference observed between female and male subjects and among groups at different education level is not significant.
 Lack of perceived benefit was also the other common barrier to voluntary counseling and testing. In poorer high prevalence areas, many people did not want voluntary counseling and testing service. Because they may afraid that little help will be available to them if they are infected and there fore, it is better not to know their serostatus. Therefore, people may perceive that voluntary counseling and testing is not much important for those who have low socio-economic status. Most (61.5%) respondents answered economic status couldn't be a barrier to the use of voluntary counseling and testing. But the remaining 38.5% respondents replied that economy become a barrier to the service or not.
 Analysis regarding to this idea was made based on sex and education level. There was no difference in the response of male and female respondents. Sixty one percent male and sixty two percent female respondents replied that socio-economic status affect the up take of voluntary counseling and testing. Those (86.5%) illiterate, (64.3%) primary, and 61% secondary level educated respondents replied that socio-economic status did not affect the use of voluntary counseling and testing while (54%) of the tertiary educated level respondents replied that the need to voluntary counseling and testing can be affected by socio-economic status. Analysis made on sex shows that there was no significance difference on their knowledge towards problems associated with voluntary counseling and testing. But there is significant difference among subjects in their education level as shown in the analysis table.
 Respondents' attitude to HIV/AIDS
As indicated in different research and findings voluntary counseling and testing is used to make people, aware of HIV/AIDS mode of transmission and prevention, function and problems associated with voluntary counseling and testing.
 Most respondents disagree with idea raised like sharing a meal, with HIV infected individuals and purchasing food items transfer HIV/AIDS. Respondents have good attitude towards the way how HIV/AIDS could be transmitted from infected to uninfected persons. This also can be gained through voluntary counseling and testing services.
 On the other hand the respondent's attitudes towards HIV prevention mechanisms, 64% of them agree that abstain from pre-marital sex is important and 46% of the respondents disagree with buying condom from shop or other place is embarrassing. This indicates that respondents have good attitude towards the use of HIV preventing mechanisms.
 In addition, 38.5% of the respondents were uncertain that whether HIV/AIDS is God's punishment or not. This indicate people may have a perception HIV/AIDS is a disease of sinners. It is a great problem which creates negative image in the mind of the respondents towards people, who are living with HIV/AIDS. Moreover, 86% of the respondents agree that free discussion on HIV/AIDS in the family is necessary.
 A t-test was used to see whether there is an attitude difference between male and female subjects with the above stated ideas. But the result did not show any significant different between groups towards the HIV/AIDS prevention and transmission mechanism.
 One-way ANVOA test was also used to see whether there is an attitude difference among groups of respondents. There was a statistically significant difference among groups. The difference show attitude towards HIV/AIDS decreases as education level increases except tertiary education level.
Attitude towards voluntary counseling and testing
Until recently, many people believed there were few benefits to knowing their serostatus. But Voluntary counseling and testing have various advantages to the needy. To this end voluntary counseling and testing service is used to adjust the life style of tested people, for psycho-emotional support, to make informed decision about HIV test, was raised. To these questions 62%, 59.5% and 72% of the respondents respectively agreed. From this we can understand that respondents' attitude towards voluntary counseling and testing service and its advantage is better the study community.
 Moreover, 44% of the respondents replied that voluntary counseling and testing is advantageous for infected women, who know their sero-status, to make informed choices about their reproductive lives. Further, voluntary counseling and testing provide information on the increased risk of opportunistic infections of sexually transmitted diseases.
 Further analysis on the advantage of voluntary counseling and testing was made based on sex and education level. The t-test analysis shows that there was no statistically significant difference between groups of male and female subjects in their attitude towards the advantages of voluntary counseling and testing services.
 One-way ANOVA was used to see whether there is an attitude difference among groups based their education level. The result showed that there was a significant difference among the groups in their attitude towards the advantages of voluntary counseling and testing services. That is as education level increases, the attitude towards the benefits of voluntary counseling and testing also increases.
 In addition to the above discussions, various questions related to problems associated with voluntary counseling and testing was raised and the result has been analyzed. Seventy four percent of the respondents disagree with People who went to voluntary counseling and testing have certain health problem. This indicates that even people had no problem of health they have to go to the service to check their HIV status or for other reason.
 Stigma and discrimination threatened people in order not to reveal test result. Here, forty seven percent of the respondents agree with the idea. Mostly people are not voluntary to go to voluntary counseling and testing, because they worry a lot about HIV test result. Forty seven percent of the respondents did not worry about their HIV test results. The two concepts above seem to have opposite response. People fear stigma and discrimination but they were not worry about the test result. This idea generates the concept that most people fear not the test result but the stigma and discrimination after the test, such attitude towards voluntary counseling and testing may reduce the use of the service.
 The other problem related to the attitude of respondents towards voluntary counseling and testing was fear of taking test result. But 45% of the respondents disagree while 40.5% the respondents agree. Seventy four percent of the respondents disagree that voluntary counseling and testing institutions in their area provide adequate service to clients. Thirty eight percent of the respondents hesitate to go to the voluntary counseling and testing service, because the service provided after test is not sufficient. This may hinder people from seeking voluntary counseling and testing services because of their economic problem. Fifty five percent of the respondents disagree that staying without test is better than being tested.
 With the attitude of people towards problems associated with voluntary counseling and testing further analysis was made on sex and education level. There was no statistically significant difference between male and female subjects. But one-way ANOVA showed that there is significant difference among groups at different education level. The analysis showed as the education level increases, there is a consistent decrease in the attitude of respondents to the problems associated with voluntary counseling and testing.
Suggestion
On the basis of the findings the researcher forwards the following suggestions.
 The result indicates that numerous numbers of people are aware of the advantage and problems associated with voluntary counseling and testing. But the practicability or using of voluntary counseling and testing was very low due to different factors that prohibit individuals in order not to use the service. Therefore, sensitivity program on the issue of voluntary counseling and testing and its physical, psychological and social benefit to people should be advocated by responsible bodies like government, non-government and civil societies
 More specifically, stigma and discrimination are the most significant factors which affect the use of voluntary counseling and testing. Therefore, exhaustive education, workshop for significant people like religious leaders, youth associations who are working in the area of HIV and other influencing bodies should be given to increase people's awareness on the negative consequences of stigma and discrimination.
 Institutions which give voluntary counseling and testing service should be available and equipped with necessary materials to give the adequate service needed by people. Moreover, these centers should have professionally trained counselors and "counselors" who are found in the institutions should get the appropriate training in order to treat clients empathetically.
- In addition, worrying about HIV test and fear of taking the test result affects the attitude of people towards voluntary counseling and testing. So to solve such types of problems, counselors should give the appropriate pre-test counseling for clients. This helps to make decisions on HIV test and taking the result with out hesitation. Moreover, post–test counseling should also be given for the purpose of emotional and social stability of HIV infected persons.
 Eventually, further research should be conducted on the basis of other factors, since there could be different factors which were not included in this study.
Acknowledgement
 First and for most, I would like to thank my advisor R. Venkatalhm, professor at Addis Ababa University for his critical and constructive comments in the course of the study.
 I would like to extend my sincere gratitude to my wife W/ro Beletu Tesfaye, who performs all the data gathering activity. My special thank is to my friends Ato Wededegn Argaw and Ato Molla Alehegn for their moral and material support. Moreover, I would like to thank my brother Keya leul for his coordination and facilitation of data collection along with W/ro Beletu Tesfay.
 I would like to express my thanks to the kebele chair persons of the selected sites for their nreserved co-operations in providing the required information.
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