Table 1 provides a summary of socio–demographic characteristics of the study participants. A total of 1257 participants (66% females) were enrolled in the quantitative study. The average age of participants was 28 (SD=11) years and the majority (68%) were between ages 19–34 years. Slightly over half (55%) of the participants had attained primary level of education followed by secondary education (37.5%); and, a small number (6.5%) had attained tertiary education. There were more females (61.90%) reporting primary level than other levels of education while among males, the majority (47.90%) reported secondary level than other levels of education. Slightly over half (53.5%) reported they were married. Compared to their male counterparts, slightly more females (56%) were married than the males (48%). Overall, 39.9% reported no occupation and a similar proportion (39.4%) were engaged in unskilled jobs. The majority of females (52.80%) had no occupation compared to the males where 53.30% were involved in unskilled jobs with 66% of them employed. Among the females the majority (69%) had no employment.

Out of the 1257 participants, 1,078 (85.9%) had ever tested for HIV, with 74.2% having tested in the Kibera HBTC program (Table 1). Of those who had tested in HBTC, 97.4% rated HBTC experience as either excellent (62.4% of participants) or good (37% of participants) and reported they would recommend HBTC to a friend. The majority 662 (61.8%) of those who had received HBTC reported having received subsequent testing for HIV in hospital. Of those reporting previous testing in HBTC, 25 participants (2.4%) self–reported being HIV positive. Of those reporting HIV negative status, 1222 (99%) accepted testing. A total of 39 (3.4%) participants who reported previous HIV negative test results, tested HIV positive in this study; 28 (72 %) of them having been tested previously at the Kibera HBTC program.

Most of the participants (82.8%) reported having had a condom demonstration at the last HBTC, but only 39.6% reported having been offered condoms at the time, out of which 97.2% declined to take the condoms citing no need for them. Of the 28 HBTC participants who tested HIV positive in this study, the majority 23 (82%), had received condom use demonstration but only three (15%) participants out of the 28 reported they had used condoms always in the last 3 months. Seventeen participants reported no condom use, of those, 11 (64.7 %) reported that they trusted their sexual partners, 5 reported they did not trust their partners and one participant reported partner refusal to use condom while three did not respond to the question.

Table 2 provides the proportion of participants reporting receipt of prevention messages across all sites (HBTC, Hospital, VCT, workplace, and mobile outreach sites) in descending order. The highest reported was Condom use (85%), faithfulness (72%) and partner reduction (57%). Testing location was associated with messages provided: faithfulness (78% in HBTC versus 67% in other sites (p=0.001)), partner reduction (64% in HBTC versus 52% in other sites (p=0.001)). Although there were slightly more participants reporting receipt of condom use demonstration and counseling at other testing sites (85.4%) than in HBTC (83%), this was not significant (p = 0.367). STI treatment messages, on the other hand, were more prevalent at other testing sites (23%) than in HBTC (16%, p=0.012). STI prevention and treatment messages was least reported in all sites

The unadjusted results for prevention messages delivered during HBTC (Table 3) suggest that reported delivery was: higher among females (553) than males (266) (OR=1.45, 95% CI=1.11–1.90,AOR =1.21, 95% CI 0.88–1.66); significantly higher among individuals 25–34 years (AOR=1.8, 95% CI=1.09–2.95) AOR = 1.84(1.01–3.37) and those 55–64 years (OR=3.22, 95% CI=1.08–9.59), AOR=3.51(1.07, 11.54) compared to those 13–24 years; and higher among married and separated individuals compared to those that were single. However, the adjusted results suggest that age, occupation and marital status were the main factors associated with levels of access to prevention messages in HBTC. Overall, there were more respondents in the middle index category, 339 (41%) than the low index category 286 (35%) and the high index category 194 (24%).

The majority of the participants (80%) reported they had never used condoms in their lifetime despite receiving demonstration on how to use it at previous HBTC, and only 10.7% reporting consistent use of condoms. Of those reporting no condom use at the last sex, 80.7% reported they trusted their sexual partners. Only three percent (3%) of the participants reported partner refusal to use condoms.

In bivariate analysis (Table 4), adoption of safer sexual practices including (use of condoms, partner reduction, faithfulness to one sexual partner of known HIV status) for behavior change was associated with all the covariates considered except employment status and whether the partner was new or not. Overall, most participants reported no change in risky sexual behavior with men were more likely to report practicing safer sex after learning their HIV status than females (p = 0.002) and this declined with age but increased with education. Marital status was found to be negatively associated with the adoption of safe sexual practices, with married individuals less likely to adopt safe sex practices compared to singles (Adjusted Odds ratio (AOR))=0.09,95% CI=0.02–0.28). The results also suggest that individuals with moderate levels of access to prevention messages in HBTC were more likely to adopt safe sex practices compared to those with low levels of access. However these practices were less likely in those with high levels of access to prevention messages. The participants whose last testing site was a VCT center were more likely (33%) to use protection than those who tested at home (22%), and in hospital (13.2%).

A total of six focus group discussions were held comprising of 18 women and 27 men.

All the participants had heard of HTC and were aware of the different sites to obtain the services in general. The majority of the participants were satisfied with the services; they reported that HBTC was a convenient and confidential strategy eliminating fear; that the providers’ approach and demeanor were very polite and that they explained everything in detail.

“HBTC saves time you will be tested when cooking your meal” (Female, 31–50 years)

“I had been planning to go, but always doing something for the first time is always very difficult. I even had gone to the testing center and gone back home without testing (Male, 18–30 years)

However, a few participants reported concerns that some providers were in a hurry and also not sensitive to the presence of children as they introduced the topic of HIV testing and conducted condom demonstration.

“The first thing they say is that we do HIV counseling and testing without separating the children, they go as far as explaining how to use condoms and the children are underage” (Male, 31–50 years)

Some service providers were reported to be gossipers and were often heard talking about their experiences in the households they had visited as they walked through the community.

“They should not follow one another tike “kobe kobe” (tortoise) because when they do, they get time to gossip……” (Male 18–30 years)

The FGD participants reported that testing for HIV in this community was regarded as normal following the HBTC service offered previously and reported having re–tested several times thereafter but prior to that, people especially men feared to test for HIV and assumed the results of their sex partner was same as theirs.

“When I was tested, my husband was in the house but did not wake up. He just said ‘when I hear your status is bad, please I will be the way you are found” (Female 31–50 years)

“I had gone to AMREF before you started coming to our houses, when I arrived at the gate to start taking the stairs, it was like I was beaten because I looked at the way people were seated at the bench, and you see your friends who are already infected.……” (Male, 31–50 years)

Participants expressed the desire to have HIV testing services taken to the community more frequently.

“We should be given services after 1–2 months, this because of the way we interact with one another and the situation we live in” (Male 31–50 years)

Participants also reported that many of them accessed HTC services in groups of friends and that this was a common practice among the residents as they were aware that they shared sexual partners.

“I could have a girlfriend and have “raha” (Kiswahiii word for fun) with her and wish her goodnight. You will then meet with her in the morning from her night activities; this means that she never spent the night at her place. A iady like this could have sex with all men in the community. This makes us to test together as men” (Male 18–30 years)

All the study participants were unanimous that they were given good and useful information during HBTC on how to protect themselves against HIV infection including; need to know ones HIV status, use of condoms, partner testing, faithfulness to one sexual partner, reduction of sexual partners and taking medication if found HIV infected. However, while some said the information was new, others reported that it is not new but that in the home it was given in a friendly way and they also had the chance of testing with their spouse.

“I was told I could use a CD (condom) or that I could be faithful to one partner. He also told me that if I had HIV I could use some drugs and we also discussed where I could get them” (Male 18–30years)

“They also ask you if you are married or in a relationship and the importance of being tested together” (Female 31–50yeras)

“Like for me who has a partner when I go to the dispensary to test and tests negative and may be my partner is positive…. So when they come, they will make you know the reality if you are together and test you as a couple (Female 31–50Years)

There were mixed responses about use of prevention messages with the majority expressing that they were not used. It was reported that, by and large, condoms are mainly used by the younger people and that use of condoms in marriage is challenging as it is viewed with suspicion on the part of the partner suggesting its use.

“Using condoms means that you have other affairs…..” (Male, 18–30 years)

“That information is not effective I know three people who are HIV positive and they are not using condoms” (Female, 18–30 years)

“When I was tested and found negative I added another wife and she gave me a child. We were tested last year with my partner and we were found to be negative but I have another sexual partner but we have never tested together” (Male 31–50 years)

The reports suggested that the decision to use condoms is left to the man who is seen to be in control.

“Men are usually so fast when they come to you, you might think that their mind is there putting on that condom. You may be cheated that he has put it on and with you, you are tying there waiting for a man to get inside you” (Female 18–30 years)

Participants’ reported that there was extensive casual sex without use of protection among the residents in the informal settlement both among those HIV infected and those not infected.

“In this life we live, we have sexual intercourse… with your girlfriend. Let me say you are married and then you have this one else somewhere and you have sex or by bad luck you were with someone else taking……”laughter. (Male – 31–50 years)

In addition to trust of the sexual partner reported in the quantitative study, the FGD participants also reported that those who are HIV positive do not use condoms as they argue there is no need because they were already HIV infected. Additionally condom use was perceived to be associated to early death by those infected with HIV, this hindered condom use.

“… Those who are positive do not see the need to use condoms even after getting explanation from doctors on how to use them for they argue that you cannot take a sweet with a wrapper and that makes them die quickly.” (Male 31–50 years)

“If those in HIV programs were consistent in condom use then they would not be giving birth at this rate. You find women who have been advised to use condoms to prevent re–infection continue to give birth” (Female, 31–50 years)