HIV Testing and Counseling for Women
- HIV testing and counseling (HTC) can help women know their HIV status and increase their protective behaviors, particularly among those who test HIV-positive.
- Providing HIV testing and counseling together with other health services can increase the number of people accessing HIV testing and counseling.
- Mass media interventions can increase the numbers of individuals and couples accessing HIV testing and counseling.
- Community outreach and mobilization can increase uptake of HIV testing and counseling by reaching clients who may not present at a hospital or clinic.
- Home testing, consented to by household members, can increase the number of people who learn their serostatus.
- Counseling may reduce risk behaviors and HIV acquisition.
- Incorporating discussions of alcohol use into HIV testing and counseling may increase protective behaviors such as condom use, partner reduction and reduction of alcohol use.
- Encouraging couple dialogue and counseling, including techniques to avert gender-based violence, may increase the number of couples who receive and disclose their test results.
1. HIV testing and counseling (HTC) can help women know their HIV status and increase their protective behaviors, particularly among those who test HIV-positive.
A systematic review and meta-analysis of 18 studies published between 1990 and 2006 with 1,801 combined participants found that HIV counseling and testing led to a significant impact on condom use among HIV-positive participants than on HIV negative participants, especially among sero-discordant couples.
A randomized control trial in Tanzania, Kenya and Trinidad found that individuals over the age of 18 who received VCT significantly changed their risk behaviors compared to those who received health education. Individuals reporting unprotected intercourse with non-primary partners declined by 35% for men who received VCT as compared to 13% for those receiving health information and by 39% for women who received VCT as compared to 17% who received health education. Individual men who had received VCT reduced the mean number of non-primary partners with whom participants had unprotected intercourse from 38% to 15% and women reduced the mean number of non-primary partners with whom participants had unprotected intercourse from 43% to 22%. VCT was based on a client-centered counseling model, including personal risk assessment and developed of a personalized risk reduction plan. Participants in the health information intervention watched a 15-minute video and participated in a discussion about HIV transmission and condom use. All precipitants received free condoms and a brochure showing correct condom use. Urine samples were taken to assess if STIs were new infections. A total of 3,120 individuals and 586 couples were enrolled in Kenya, Tanzania and Trinidad.
A systematic review of the efficacy of VCT in Rwanda, Kenya, Tanzania, Trinidad, Thailand and Uganda settings in studies from 1990 to 2005 found that a significant increase in condom use was reported in four studies conducted in free-standing VCT centers, antenatal clinics, and STI clinics. One study found significant reduction in HIV incidence among ANC women whose partners also underwent VCT. The randomized control design showed a significant decrease in unprotected sex among, a) individuals with non-primary partners, and b) between couples when they were tested together. VCT was shown to promote the most behavior change between couples tested together, and among HIV-positive individuals, especially with their non-primary partners. The review used a standardized protocol. Studies were included where the intervention used CDC or WHO VCT standards; was published between 1990 and 2005, were conducted in a developing country, and used a pre/post or multi-arm study design. Nine articles from six studies were identified. Designs were 1) randomized controlled trial, 2) pre/post studies, and 3) post-intervention only assessments.
A population based open cohort study of 17,874 people in Zimbabwe with 7,559 men and 10,315 women aged 15–54 offered no-cost HIV counseling and testing through mobile clinics found that among women who tested HIV-positive, risk behaviors were significantly reduced. The effect of VCT in reducing risk behavior increased with greater time since testing positive with reduced levels of concurrency.
A longitudinal cohort study in Mozambique from 2002 to 2003 with 450 people who participated in VCT groups and 504 people who were not in VCT groups found that those participating in VCT groups increased condom use while those not in VCT groups did not. Three visits were required for the VCT group, which included both testing and counseling components. Those who did not attend VCT attended outpatient ANC clinics. Reported condom use always or sometimes was not significantly different between VCT and non-VCT groups at baseline, but was significantly higher at follow-up. Condom use at most recent sex was the same in both groups at baseline but became significantly more frequent in the VCT group. Condom use during the most recent sexual act increased over time for both HIV-positive and HIV-negative people, but the increase was greater in those who were HIV-positive. Change was most significant for those with no literacy skills, showing the importance of interpersonal communication: for those attending VCT an increase from 10% to 64% at the end of the project.
A cluster-controlled trial with seven intervention and 14 control clinics in South Africa with STI patients (57.2% female in the intervention clinics and 57.5% female in the control clinics) found that a significantly higher proportion of new STI patients in the intervention group tested for HIV. The intervention clinics had provider-initiated tested as compared to the control clinics, which used VCT. In the 3,053 patients in intervention group, 56.4% of STI patients tested for HIV, with 26.7% declining to test. High rates of declining HIV testing indicated that patients could exercise their right to decline testing. There were 6,027 STI patients in the control group. The odds ratio for getting an HIV test was 2.24 for the intervention group compared to the control group. Acute, non-recurring STIs create limited opportunities to offer HIV testing. Providers in the intervention group recommended that patients be tested for HIV, obtained written consent and performed a rapid HIV test. Patients were referred to lay counselors for test results and post-test counseling once they completed the STI consult and HIV testing. STI nurses from the intervention sites received a two day training course. No significant outcomes by sex were noted.
A cross-sectional survey in South Africa between 2004 and 2005 found with 198 men and women found that of those who had disclosed to a main partner, 46.6% started using condoms as a result of HIV testing and 43.8% reported that their partner also went for HIV testing. Of those who disclosed, 8.2% reported that their relationship ended as a result of disclosure and 4.1% reported being physically hurt as a result of disclosure. Among those who reported having previously tested for HIV, 90.3% reported having disclosed to someone and, of those who disclosed, 86.9% had disclosed to a sex partner and this did not differ by sex.
A cross-sectional survey of 749 men and 906 women in Kenya found that women who had undergone recent HIV testing were less likely to report high-risk behaviors than women who had never been tested. This was not seen among men.
A cross-sectional and nationally representative study from 2004 to 2005 in Uganda of 1,092 HIV-positive people, 64% female, from an HIV/AIDS Sero-Behavioral Survey which tested 18,525 adults found that knowledge of one’s HIV status, both one’s own and one’s partner’s, was associated with increased condom use. Those who knew their HIV status were three times more likely to use a condom at last sex encounter and those who knew their partners’ HIV status were 2.3 times more likely to use condoms. Of all sexually active HIV-positive adults, 80% reported only one sexual partner in the previous year. Within the subset of married HIV-positive persons, 86% reported having had sex only with their spouses in the last year, including 75% of men and 96% of women. Of all married HIV-positive persons, 13% reported only one sexual partner in their life (1% of men and 23% of women). Of the 81% of HIV-positive married persons who did not understand that HIV-discordance was possible within couples, 92% did not know the HIV status of their spouse.
Interviews with 127 patients (42% male) in May 2006 in a large public hospital HIV clinic in Santiago, Dominican Republic found that sexually active patients reported using condoms significantly more frequently following their HIV diagnosis and were more likely to use a condom if they believed their partner did not have HIV. Most patients (72.4%) were sexually active. Following their diagnosis, 72.8% of sexually active patients used condoms more frequently. The most common reason cited for not using a condom after HIV diagnosis differed by sex: men cited decreased sexual pleasure (70%) and women reported that their partner had refused to use a condom (71.8%). Sexually active patients who believed that their partner did not have HIV were more than 16 times more likely to report condom use at their last sexual encounter than those who did not know their partner’s HIV status. Those who reported their partner was HIV-positive were estimated to be more than twice as likely to use a condom as those who were unsure of their partners’ HIV status. One-third reported using a condom every time they had sex following their diagnosis. A majority of men had ever paid for sex (80%), while only one woman (1.4%) had ever paid for sex.
A study of 963 cohabitating heterosexual couples with one HIV-positive and one HIV-negative partner in Rwanda, found that less than 3% reported condom use prior to VCT. The frequency of sex did not change after joint VCT, but the proportion of reported contacts with a condom increased to over 80% and remained stable through 12 months of follow-up. Couples with regular appointments thorough one year reported more frequent intercourse with condoms than couples with missing appointments. At baseline, 21% of HIV-positive men and 15% of HIV-negative men in discordant couples reported at least one sexual encounter outside the marriage in the last three months. These contacts represented 7% of all acts of intercourse in the three months preceding the study, decreasing to 3% during the first year of follow-up. Thirteen percent of incident HIV infections were acquired from an outside partner.
A quantitative study in Zimbabwe of 4,429 young men and women, complemented by informal confidential interviews and focus group discussions, found that young women found to be HIV-positive in the survey were almost two and a half times more likely to report consistent condom use if they previously had an HIV test.
A qualitative study of in-depth interviews with 15 women, 15 men and 15 couples in Tanzania, including 10 seroconcordant HIV-negative couples, found that among seroconcordant HIV-negative couples VCT was an important strategy to encourage couples who may be at risk for HIV infection to initiate preventive health behaviors to maintain their HIV-negative status. “Couples described testing as a preventive health measure they used prior to unprotected sexual intercourse, marriage or pregnancy” (Maman et al., 2001b: 597).
A review of data from 157,423 visits, of whom 117,234 clients were first time clients from VCT centers in Botswana (Tebelopele) found that clients previously tested at the VCT centers were much more likely to use condoms than were first time clients. Free-standing VCT centers were initiated in 2000. Testing demand increased steadily from 2000 to 2002. A rapid increase of testing was found following the introduction of ARVs in 2002. By the beginning of 2003, more than 20% of clients reported that their reason for seeking a test was illness or wanted access to treatment. The percentage of clients who were HIV-positive increased from 26.3% before the launch of the national ARV program to 38.8% after ARVs were available. Among those seeking a test for health reasons, 77.7% were HIV-positive. Clients who came for testing as part of a couple made up 8.2% of all clients, with no change over the five year period. Discordant results were found in 23.1% of couples. Since 2003, 16 VCT centers were opened, with free anonymous HIV rapid testing with same day results. All counselors have 8 weeks of training in counseling and testing, and many are university educated. A one hour standardized counseling and testing protocol takes approximately one hour. Information was collected anonymously from clients including sexual history, reasons for seeking an HIV test and the test result. Multivariate analysis was used.
2. Providing HIV testing and counseling together with other health services can increase the number of people accessing HIV testing and counseling. [See also Structuring Health Services to Meet Women’s Needs]
A study in Ethiopia found that incorporating VCT into a reproductive health facility greatly increased the numbers of those who accessed VCT, with those accessing VCT having high HIV prevalence rates. The study used 30,257 VCT client records from Family Guidance Association of Ethiopia (FGAE), a non-governmental non-profit providing reproductive health services in clinics. When both VCT and family planning were either in the same room or offered by the same counselor, clients were 1.9-7.2 to initiate HIV testing than if VCT and family planning were simply offered in the same health facility. Relative to facilities co-locating services in the same compound, those offering family planning and HIV services in the same rooms were 2-13 times more likely to serve atypical family planning client-types than older, ever-married women. Facilities where counselors jointly offered HIV and family planning services and served many repeat family planning clients were significantly less likely to serve single clients relative to older, married women. Younger, single men (78.2%) and older, married women (80.6%) were most likely to self-initiate HIV testing, while the highest HIV prevalence was seen among older, married men (20.5%) and older, married women (34.2%). FGAE attracts both pregnant women, who are at high risk for HIV, and young, single people who want to initiate VCT.
From 1985-2000, the Group Hatien d’Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), an NGO with a VCT center in Haiti increased the integration of additional health services. The number of new people seeking VCT increased from 142 in 1985 to 8,175 in 1999, a 62-fold increase. Of new adults seeking VCT in 1999, GHESKIO provided AIDS care to 17%, TB treatment to 6%, STI management to 18%, and 19% became new users of a contraceptive method. Of the 6,709 adults coming for VCT in 1999, 36% benefited from at least one service visit. Of the 2,013 adults who tested HIV-positive, 56% benefited from at least one service visit and 21% referred a sexual partner for VCT. One hundred ten HIV-negative sexual partners of HIV-positive individuals were identified, and of these, 85 returned for repeat HIV testing after a median of 18 months, and none of these 85 seroconverted. The prevalence of HIV among patients served by GHESKIO was 30% or six times the prevalence rate in the general adult Haitian population. On their first visit to GHESKIO, individuals are assisted to develop a personalized HIV risk reduction strategy. Patients reporting a history of cough for more than 3 weeks are provided on-site, same day TB screening including clinical exam and sputum smears. Patients with STI symptoms are provided treatment based on algorithms. All patients are screened for syphilis. Same day pregnancy tests are conducted. Condoms are provided. All patients are encouraged to obtain family planning. Post-test HIV-negative patients are counseled in groups of 5. All HIV-positive patients are counseled individually, encouraged to refer sexual partners and offered comprehensive HIV care, including HAART for all adult patients, PMTCT, long-term access to HAART when women give birth, treatment of opportunistic infections, home care, education to family care givers, and nutritional support. Availability of other reproductive health services may encourage people to access VCT despite the fact that “people diagnosed with HIV/AIDS in Haiti still risk tremendous social stigmatization” (Peck et al., 2003: 474). The study conducted a retrospective review of patient records.
A 2005-2007 study in Kenya using a pre-post design found that provider-initiated testing and counseling is feasible and acceptable in family planning services, does not adversely affect the quality of the family planning consultation and increases access to and use of HIV testing in a population who would benefit from knowing their status. One group of 28 family planning providers were trained for nine days in integrated family planning and HIV testing and counseling to family planning clients, using rapid HIV tests and another group of 47 planning providers were trained for five days to refer clients interested in a HIV test. Staff in the intervention clinics were updated on contraceptive methods, STIs and HIV, reproductive rights, informed choice and consent, safe sex and dual protection, values clarification, risk assessment and reduction, record keeping and logistics management. The proportion of clients requested an HIV test increased from 1% to 26%, with approximately one-third of these never having had an HIV test previously. In 2003, 38% of all women who had intercourse in the previous month and 44% of unmarried women who had had intercourse in the previous month reported using a contraceptive method, with the majority of these women attending clinics for family planning. The study took place in twenty-three public sector hospitals, health centers and dispensaries. Focus group discussions were held prior and following the intervention. Implementing the intervention required two to three minutes per client. For clients who decided to have an HIV test with the family planning provider, the median time increased from 10 minutes to 17 minutes, which included time both for the HIV test and counseling the client on the result. The incremental cost per family planning client ranged from USD$5.60 per client in the hospital to $9.63 in the dispensary and compares favorably with an estimated cost of $27 per client for stand-alone VCT.
In a cross-sectional study of 8,444 women who attended an STI clinic in South Africa from 2005 to 2006, 5,612 women were provided with information and education and were offered provider-initiated HIV testing. Of the 5,612 women offered provider-initiated HIV testing, 2,439 accepted HIV testing. Of those who accepted HIV testing, 56.5% or 1,378 out of 2,439 tested HIV-positive. Counselors had completed secondary school and training and used interactive role-playing with a structured script. Topics covered included reasons why one should know one’s HIV status, consequences of an HIV test result, preventive behavior, stigma, and referral for treatment, with each session lasting 20 minutes per group of no more than eight women, with questions encouraged. Those consenting to HIV testing had a shortened individual pre-test counseling session of approximately 15 minutes duration concerning personal risk.
3. Mass media interventions can increase the numbers of individuals and couples accessing HIV testing and counseling.
A Cochrane review of mass media interventions for promoting HIV testing, which included 35 references with two randomized trials, three non-randomized controlled studies and nine interrupted time series found that mass media was significantly effective in promoting HIV testing.
Retrospective analysis of data of VCT for the two six-month periods before 2007 and after the 2008 National VCT Campaign in Tanzania found that that the National VCT Campaign led to increased testing for those who tested HIV-positive and for those who tested HIV-positive to subsequently enroll in HIV care. Of the 4,354 individuals who tested for HIV in 2007 before the national campaign, 23% tested HIV-positive in 2007 as compared to 26% who tested HIV-positive in 2007. Of those who tested HIV-positive after the National VCT campaign, more individuals tested who lived further than 10 kilometers from the VCT testing site. In the 356 HIV-positive people with available data, the median CD4 cell count increased from 137 to 163 following the campaign.
A study of scale up in Kenya of VCT from three sites in 2000 to 585 sites in 2005 using VCT client data from 131 VCT sites with 131,160 client records found that intensive mass media campaigns concerning VCT was correlated with increased utilization of VCT. The mass media campaigns accounted for only 10% of the total costs of the VCT program.
4. Community outreach and mobilization can increase uptake of HIV testing and counseling by reaching clients who may not present at a hospital or clinic.
HIV testing was increased between 2006 to 2009 among residents aged 16–32 by a combination of community mobilization, mobile community-based VCT and support after testing in 10 communities in Tanzania, eight in Zimbabwe and 14 in Thailand as compared to standard clinic-based VCT. Randomization and assignment of communities to intervention groups was done by the statistics center by computer. The proportion of clients receiving their first HIV test during the study was higher in community based VCT as compared to standard clinic-based VCT in Tanzania (37% as compared to 9%), Zimbabwe (51% as compared to 5%) and Thailand (69% as compared to 23%). The mean difference in the proportion of clients receiving HIV testing between community based VCT as compared to standard clinic-based VCT was 40.2%. The number of people receiving their first HIV test was much larger in community based VCT communities than in standard clinic-based VCT communities by four times in Tanzania, nine times in Zimbabwe and three times greater in Thailand. Community based VCT detected almost four times more HIV cases than did standard clinic-based VCT across all three study sites. Women constituted 42% of clients in community based VCT in and 47% of standard VCT in Tanzania; 48% of community based VCT and 46% of standard VCT in Zimbabwe; and 55% of community based VCT and 66% of standard VCT in Thailand. In Tanzania and Thailand, a larger proportion of male clients participated in community based VCT as compared to standard clinic based VCT. All study sites were rural.
A 2006 and still ongoing study that randomized communities to either a multilevel intervention providing community-based HIV mobile VCT in 48 communities in Tanzania, Zimbabwe, South Africa and Thailand or clinic-based VCT found that HIV testing uptake increase three-fold in the communities with mobile testing, with 21,391 people tested. In the intervention communities, community mobilization and post-test services of support groups for both HIV-positive and HIV-negative to maintain negative status were instituted, counseling, training workshops, stigma reduction workshops, and information sharing sessions as well as mobile VCT. In additional, outreach workers and volunteers were used to increase access to VCT and make awareness of HIV status more acceptable in community settings.
A home-based HIV testing and counseling program from 2004 to 2007 in rural Uganda where prior to 2004 about 90% of the population had never had an HIV test resulted in 282,857 being offered pretest counseling out of a total population of 323,621. Of those counseled, 94% accepted an HIV rapid test and all received their test results. Those who tested HIV positive received condoms, cotrimoxazole prophylaxis, long-lasting insecticide treated bednets, equipment to treat drinking water at home and were referred for assessment for antiretroviral therapy. The cost of testing was US$7.83 per previously untested client and US$139.32 per HIV-positive individual identified. Of those tested, 4.3% tested HIV-positive. Of those who tested HIV-positive, 97% initiated cotrimoxazole prophylaxis 74% received bed nets, 70% received water treatment equipment and 11% began antiretroviral therapy. CD4 test results were delivered to people in their homes. Shortages of water vessels and bed nets meant that not all who tested HIV-positive received these. “A private place in the house or within the garden was used for posttest counseling and giving of results” (Tumwesigye et al., 2010: 736). Counselors employed had a nonmedical background. Pregnant women who tested HIV-positive were referred for PMTCT and HIV-positive people who had coughed for more than two weeks were referred for TB diagnosis. Support groups were formed for sero-discordant couples and for those who tested HIV-positive.
A study from 2002 to 2003 in rural Thailand with people over the age of 16 found that mobile HIV testing increased the number of people testing. Of the 427 people who were tested via mobile VCT, 131 had had a prior HIV test. Prior to testing, HIV education was launched in communities. Two-way communication and group discussions were used for the educational programs conducted at a convenient location in the community. Confidential or anonymous testing was provided. Those who chose confidential testing were provided a study unique number for receiving test results. People received pre-test counseling, HIV testing, and post-test counseling and test results by trained counselors. Non-testers were randomly selected for interviews and testers were also interviewed. 427 people who participated in community based VCT were compared to 389 community non-testers. A total of 31 village leaders, 54 testers and 43 non-testers were interviewed in-depth and all three groups viewed community testing positively due to convenience and no cost.
An analysis of a retrospective cohort of 62,173 individuals receiving HTC from 2005 to 2006 in Kenya found that mobile HTC reported a higher proportion of clients with no prior HIV test (88%) as compared to stand-alone HTC. Stand-alone HTC reported a higher proportion of couples (18%) as compared to mobile HTC (2%). Stand-alone HTC also reported a higher proportion of discordant couples (12%) as compared to mobile HTC (4%). The incremental cost-effectiveness of adding mobile HTC to stand alone services was $14.91 per client tested as compared to US$26.75 for standalone HTC. Costs for mobile HTC was $16.58 per previously untested client as compared to $43.69 for standalone HTC and $157.21 per HIV-positive individual identified as compared to $189.14 for standalone HTC. Overall, the incremental cost per outcome achieved was lower when mobile HCT was added to stand alone services. The cost per HIV-positive client identified and new HIV-positive client identified was lower for mobile HTC than stand alone HTC. Women are more likely to access HTC at community sites rather than at stand-alone sites.
A study in Zambia from 1995 to 2000 found that community workers who promoted couples counseling in their neighborhoods significantly increased the numbers of couples who tested jointly. Previously tested couples were trained for three days to be community outreach workers: “Like you, I am married and have been tested with my spouse” (Chomba et al., 2008: 109). Community workers emphasized the importance of testing together and explained that one person in a couple can be HIV-positive and the other can be HIV-negative. Services were confidential. Complex questions were referred to counselors. Once outreach by community workers was discontinued, couples VCT dropped by 90%, from 230 couples per month to 20 couples per month when promotion was limited to mass media. Of the 8,500 cohabitating couples who sought HIV testing, 51% were concordant HIV-negative; 26% were concordant positive; and 23% were couples with one partner positive and the other partner negative. Each couple spoke privately with a counselor in deciding to test. Individual counseling was provided on request. Transport, childcare, lunch and counseling were provided whether couples elected to test or not.
Data collected on utilization, costs and outcomes of VCT services in a hospital clinic with 568 clients (56% male), in a community HIV clinic with 28 clients (91% male), in a STI community clinic with 574 clients (53% male) and a prison clinic with 574 clients (no sex disaggregated data) in Indonesia from 2008 to 2009 found that the cost was lower in the HIV community clinic with a unit cost of $39 and in the prison with a unit cost of $23 followed by the STI community clinic with a unit cost of $65 and the most expensive being the hospital clinic with a unit cost of $74. Costs were calculated for both resources in the health care system as well as costs accrued by patients accessing care. Costs accrued by patients were obtained from a survey conducted in 2009 which collected information on travel costs, travel time, income, working hours and expenditures. Most HIV-positive cases were detected at the hospital, with 38% testing HIV-positive, as compared to 14% at the community clinic, 3% at the STI clinic and 7% in the prison. Most patients diagnosed through VCT in the hospital and the prison who tested HIV-positive enrolled in HIV care whereas few did so in community clinics. Patient costs were lowest in the community clinic, which needs more effective referral systems to HIV care.
Using data from two sub-studies on client-initiated VCT provided in rural health centers and researcher-initiated VCT provided in a non-clinic community setting in rural Zimbabwe found that testing uptake was improved by using both rural health centers and non-clinic settings for VCT. Survey data was collected from 16,000 young people who were encouraged to attend VCT at local clinics, but fewer than 5% did so. By contrast when testing was offered to everyone in a non-clinic setting, 27.3% of young people chose to be tested. Data from clinic based VCT show that of 3,585 clients over the age of 18, 32.9% tested HIV positive. In the non-clinic setting, 1,368 of 5,052 of participants opted to test and 18.8% tested HIV-positive. Qualitative data from clinics found that adults, but not youth, found clinic settings acceptable with concerns about confidentiality.
5. Home testing, consented to by household members, can increase the number of people who learn their serostatus.
An analysis of a non-randomized study from rural Southwestern Uganda with 1869 participants found “very high acceptability and uptake of VCT results when testing and or results were given at home compared to the standard (facility)” (Wolff et al., 2005). In Zambia, the participants who were offered home-based testing were “4.6 times more likely to accept VCT,” while in Uganda, during the year that HIV results were offered at home, “participants were 5.23 times more likely to receive their results” (Bateganya et al., 2007: 15). Overall, the review found that “home-based testing may be an effective way of delivering HIV prevention services in populations not targeted by earlier efforts” and that “the advantages of home- based VCT may outweigh any potential adverse effects that are associated with premature disclosure from home-based VCT” (Bateganya et al., 2007: 16). However, “given the limited extent of literature and the limitations in existing studies, large-scale implementation is premature. This is particularly true in developing countries, especially in sub-Saharan Africa, where the cost and feasibility of implementing large-scale home-based testing programs is wrought with infrastructure problems, as well as cost/benefit issues in areas where HIV prevalence may differ.” (Bateganya et al., 2007: 16). These two studies were included in a 2007 Cochrane review of home-based HIV VCT interventions in developing countries.
A cluster randomized study from 2005 to 2007 of 7,184 household members of people receiving treatment for HIV in Uganda, of whom 55.3% were female, found that those who received home-based testing were more than 10 times as likely to receive VCT than those who received HIV testing in a clinic. There were 4,798 in the household arm and 2,386 in the clinic arm. 2,938 household members (40.9%) completed VCT and received their results. In the home arm, 2,678, or 55.8% of 4,798 received their test results. The proportion of HIV household members was 17.3% for those who tested in the clinic as compared to those who were tested at home (7.1%). Clinic arm participants were given free VCT vouchers and encouraged to invite household members to the clinic for VCT. Home arm participants were visited and household members were offered VCT using a three test rapid finger stick testing algorithm. Analysis of home testing found that 93% were likely to be tested at the first visit. “In this setting, HIV stigma was low, and HIV status disclosure to household members common ….” (Lugada et al., 2010: 249), though it is unclear how confidentiality was kept as the authors note: “Although consent for HIV testing was approached on an individual basis, VCT was effectively a household decision as opposed to an individual decision” (Lugada et al., 2010: 251).
In Uganda, through mobile and home-based VCT, the proportion of adults in Uganda who have ever tested and received their HIV test results increased from 4% in 2000 to 21% in 2006.
In a pilot study among 3,180 villagers in Kenya aged 15–49 exposed to a community awareness campaign, 1,984 or 63.9% agreed to be visited by counselors in their homes. Among those who agreed to be visited at home by counselors, 1,984 or 97.6% agreed to be tested and receive the results. The total cost was US$17,569, resulting in $84 per positive case detected. Adult HIV prevalence was 8.2%. The program cost was $5.88 per each person tested for HIV. Of the costs, 40% was spent on test kits and 60% on human resources. The cost included a daily stipend of $15 per counselor, $30 per supervisor and $4.60 for the community health worker for each of the 78 working days to complete the testing in the village, including three days of training. Transport costs were $.077 per day. The village, Sauri, is the site of a multi-sectoral health and development initiative called the Millennium Villages Project, which aims to accelerate progress towards the MDGs in rural Africa.
A review of a retrospective cohort of 84,323 individuals in Uganda who received HIV counseling and testing between 2003 and 2005 through one of four strategies found that household and door-to-door HIV counseling and testing reached the largest proportion of previously untested clients compared to stand-alone HIV counseling and testing and compared to hospital based counseling and testing. Hospital based HIV counseling and testing diagnosed the greatest proportion of HIV-positive individuals (22%), following by stand-alone HIV counseling and testing (19%). Household member HIV counseling and testing identified the greatest percentage of discordant couples (4%). Costs per client in 2007 US$ was: $19.26 for stand-alone; $11.68 for hospital-based; $13.85 for household member HIV counseling and testing; and $8.29 for door-to-door. More than 30% of those who tested HIV positive had CD4 counts under 200 regardless of testing strategy.
A cross-sectional house-to-house survey in Uganda in 2009 asked residents over the age of 15 if they wanted an HIV test. Of 588 participants, 408 accepting testing. Of the 408 who took an HIV test, 30 previously unknown residents were identified as HIV-positive and referred to HIV care. Most participants had never tested for HIV, but almost one-third of the 30 newly HIV-positive individuals had taken an HIV test within 12 months of prior to the home-based testing survey. However, no information was given in the study if those who tested HIV-positive did access HIV care. “Based on the reasons given by those individuals for not accepting to take the home-based test in our study such as not being emotionally prepared and having to consult with spouses or parents, it is evident that HIV programs would still need to be aware of existing barriers and seek to address them” (Sekandi et al., 2011: 5).
A population-based survey to include HIV testing with 5,035 participants in Zambia which offered HIV testing found that this increased those ever tested for HIV in the population from 18% before HIV testing to 38% following the survey which included HIV testing. Young rural men aged 15–24 had the highest levels of increase from 14% to 42%. Of those offered an HIV test, 32% accepted. Among those who accepted home-based HIV testing, 20.6% had previously been tested for HIV. The counselors did not report negative life events following offering HIV testing.
Home-based counseling was offered to 750 adults in a rural area of South Africa, of whom 90.4% accepted testing with an HIV prevalence rate of 29.7%. Standardized, confidential, individualized HIV counseling and tested with risk reduction messages for all household members over the age of 18 was conducted. For those who tested HIV positive, CD4 counts were measured using point-of-care technology, ART was provided and referrals for care were facilitated. Of those who tested HIV-positive, 94% had visited an HIV clinic by three months follow up. No social harm was reported.
Surveys between 2005 and 2007 that assessed door-to-door VCT in a rural district in Uganda found that the proportion of those who ever tested for HIV increased from 20% to 63%. The proportion of people disclosing their serostatus increased from 72% to 81%. Among HIV-positive people who knew their serostatus, condom use at last sex increased from 15% to 40%.
6. Counseling may reduce risk behaviors and HIV acquisition.
A study of voluntary HIV counseling and testing in Tanzania found that a personalized risk reduction counseling session of 40 minutes was more effective in reducing risk behaviors and STIs than watching a 15-minute video. Using information from the formative research, the counseling sessions entailed a personalized risk assessment and a personalized risk reduction plan based on level of knowledge, interpersonal situation, specific risk behaviors, and readiness to change. Participants were randomly assigned to receive either HIV counseling and testing or a health information intervention where participants watched a 15-minute video in the presence of a health information officer, who responded to their questions at the end. Couples were randomized together so that both members always received the same intervention. Participants enrolling as couples were counseled together or individually, depending on their choice. Each couple member was given individual time with the counselor. Test results were initially given individually, and then the couple was encouraged to share their results in a joint counseling session. Post-test counseling then proceeded with both members of the couple. All participants were given condoms at no cost and tested for STIs and treated as appropriate if found positive. A total of 1,427 participants were enrolled (500 men, 489 women, and 222 couples). HIV prevalence among those assigned to received HIV counseling and testing at baseline was 21% - 13% for men and 29% for women. After 6 months, although there was a reduction in risk behavior for both groups, individuals who received the counseling and testing intervention showed significantly reduced risk behavior (26% to 16%) than those who received health information only (26% to 23%).
A population based open cohort study of 17,874 people in Zimbabwe with 7,559 men and 10,315 women aged 15 to 54 offered no-cost HIV counseling and testing through mobile clinics found that women who received VCT even if they tested HIV-negative reduced their reported number of new partners compared to those who did not get an HIV test. Mean length of follow-up was 4.2 years. Counseling was provided by trained male and female nurse counselors, but was not part of a clinical trial “where services may be implemented more assiduously than they can be done when scaled up” (Cremin et al., 2010: 712).“For treatment programmes to be sustainable, reductions in incidence are required. Thus preventing new infections through the provision of high quality counseling should be another, equally important, aim” (Cremin et al., 2010: 709).
A prospective cohort study of 250 HIV-negative women and 250 HIV-negative men at increased risk for HIV acquisition in India who received risk reduction counseling at the start, six months later and twelve month later had low rates of HIV acquisition, and reported statistically significant reductions in the number of different sex partners, the number of new partners and the proportion of sexual encounters with nonprimary partners. Only two participants, one male and one female, seroconverted over 457 person years of follow up. All attended an STI clinic and had VCT. To be considered high risk, all either had to have had five or more different sexual partners; had a diagnosed STI; or having had vaginal or anal sex with a known HIV-positive partner. Counseling covered prevention techniques and reducing the number of partners. Condom use was demonstrated and condoms were provided free of charge. Condom use increased. Sessions lasted about one hour.
7. Incorporating discussions of alcohol use into HIV testing and counseling may increase protective behaviors such as condom use, partner reduction and reduction of alcohol use.
A randomized community field trial in South Africa found that a brief HIV and alcohol risk reduction workshop reduced HIV-related risks among drinkers. 117 men and 238 women were randomly assigned either a three-hour skills training on HIV-alcohol risk reduction or a one-hour HIV-alcohol information session. The three-hour program resulted in significant declines in unprotected intercourse and sexual partners, alcohol use prior to sex and increased condom use compared to the one-hour session, evaluated six month post intervention. However, effects were weakest for the heaviest drinkers.
A 2006 study in Kenya with intervention and comparison sites and follow up data was conducted at 15 static and 10 mobile VCT sites with 1,073 VCT clients found that clients from interventions sites displayed more concrete intentions to change behavior, stating that they would reduce or stop their alcohol intake. The intervention consisted of alcohol counseling, which increased the VCT component time by seven minutes. Providers did not find this burdensome. Over 90% of clients reported being receptive to discussions about alcohol use while attending a VCT center. Alcohol use is associated with high-risk sexual behavior and reduced inhibitions (Zablotska et al., 2006; Ghebremichael et al., 2009a; Kalichman et al., 2007; Fisher et al., 2007). Alcohol users are more likely to perpetrate intimate partner violence. [See also Strengthening the Enabling Environment: Addressing Violence Against Women]. Clients were screened with AUDIT and CAGE consisting of questions concerning alcohol use, such as feeling the need to cut down on drinking; feeling guilty about drinking; seeking help for drinking, etc.
A pilot study with 80 women in South Africa who reported recent substance use and sex trading were randomly assigned to a standard HIV prevention intervention or a woman-focused HIV prevention intervention. Those who participated in the woman-focused intervention reported greater decrease in unprotected sex with paying clients or with baseline than those in the standard prevention intervention. Those in the woman-focused group showed a large increase from 3% to 48% in any female condom use with boyfriends, while the standard group showed a smaller increase from 20% to 40%. Focus group discussions noted that drugs and alcohol were used prior to sex work to give the women courage to approach clients. In the woman-focused intervention women learned violence prevention strategies such as staying sober to assess the situation, communication techniques, ways to exit a volatile situation and how to actively seek community resources. At baseline, although 77% considered their substance abuse a problem, only 26% knew about substance abuse treatment and only 7% had ever been in treatment. A reduction of 15% to 5% was observed in the proportion of women reporting daily alcohol use in the woman-focused group compared to a smaller decrease of 18% to 10% in the standard group.
A study from 2004 to 2007 with 425 women in South Africa at high risk of alcohol abuse found that HIV education resulted in uptake of HIV testing, with 276 or 65% agreeing to HIV testing. HIV education addressed fear of stigma and testing for HIV, along with access to prevention, treatment and care services. Of the 425 women, 200 or 74% reported drinking five or more drinks containing alcohol on a typical day.
8. Encouraging couple dialogue and counseling, including techniques to avert gender-based violence, may increase the number of couples who receive and disclose their test results.
A study of 293 HIV-discordant couples (married or cohabitating) in Uganda who received counseling, agreed to disclose, and received counselor support resulted in 81% of HIV-positive partners in discordant relationships disclosing their status to their HIV-negative partner in the presence of a counselor. Disclosure was similar irrespective of the sex of the HIV-positive partner, with 81.35 of HIV-positive men and 80.2% of HIV-positive women disclosing to their partner. HIV-discordant couples along with a random sample of 22 HIV-positive concordant couples and 22 HIV negative concordant couples to mask HIV status were invited to meetings to discuss the benefits of disclosure and couples counseling. All who participated in the meetings were required to maintain the confidentiality of everyone in the group. The meetings discussed how disclosure allows individuals who are positive to not be burdened by disclosing by themselves and having to persuade partners to test; offers a safe environment to discuss risks; enables partners to hear messages together for better understanding; receive timely interventions, such as ARVs; facilitates communication and reduces blame. Good communication skills and how to improve communication skills between partners were covered. Myths concerning discordance, such as the HIV-negative partner cannot acquire HIV, were addressed. HIV-positive partners were subsequently contacted to encourage HIV disclosure to their HIV-negative partner. If the HIV-positive partner agreed, the counselor met separately with the HIV-negative partner to assess if the HIV-negative partner would share their test result with their partner and then met with both to facilitate disclosure of HIV results and provided ongoing support. All participants were provided health education on HIV prevention and safer sex practices, were offered condoms at no cost and VCT at no cost. All who tested positive received on-going counseling every six months and clinical management, including CD4 screening and initiation of ARVS if eligible. All who tested HIV-negative and had a partner who was HIV-positive were provided with repeat HIV testing as appropriate. Counselors were trained in group psychotherapy skills.
A study of 245 women who were enrolled after pre-test counseling and prior to the collection of test results in Tanzania found that disclosure of HIV serostatus was significantly higher for couples who discussed HIV testing prior to coming to the health center: 94.6% of women who told their partners they were going to be tested disclosed their HIV results to their partners within three months after testing, compared to only 44% of women who did not tell their partners that they were going to be tested.
A qualitative study of in-depth interviews with 15 women, 15 men and 15 couples in Tanzania, including 10 seroconcordant HIV-negative couples, found that among seroconcordant HIV-negative couples VCT was an important strategy to encourage couples who may be at risk for HIV infection to initiate preventive health behaviors to maintain their HIV-negative status. “Couples described testing as a preventive health measure they used prior to unprotected sexual intercourse, marriage or pregnancy” (Maman et al., 2001b: 597).
A study in Rwanda and Zambia that promoted couples’ voluntary counseling and testing resulted in 1,411 couples requesting couples counseling and testing. Cohabitating couples in Africa represent a large HIV risk group.
In-depth interviews with 23 sexually active adults (11 women and 12 men) receiving antiretroviral therapy in 2005 in Kenya found that disclosure and couples counseling with mutual support played a central role in sustaining safe sex. All except one man had disclosed their positive serostatus.
9. Knowledge of treatment availability can increase uptake of HIV testing. [See also Provision and Access]
A population based open cohort study of 17,874 people in Zimbabwe with 7,559 men and 10,315 women aged 15–54 offered no-cost HIV counseling and testing through mobile clinics found that 83% stated they would get an HIV test if cheap treatment were available.
A cross-sectional household survey conducted in 2007 in South Africa with 1,539 men and 1,877 women as part of a community randomized prevention trial found that both men and women who had heard about antiretroviral therapy were more likely to report HIV testing and repeat testing. Women were much more likely to report both first time (64.8% of women compared to 28.9%) and repeat testing compared to men.
A cross-sectional study during 2004 of 184 men and women (121 were women) attending a hospital for any reason in South Africa found a significant association for women between those who knew someone on antiretroviral therapy and having been tested for HIV. Among women, 68% of those who knew someone on ARVs had had an HIV test as compared to 48% of women who had a HIV test who did not know someone on ARVs.
A study of 12 focus group discussions, half with women, in Uganda found that participants affirmed the incentive for testing was the possibility of accessing free ART. Prior to ART, “testing for HIV was perceived as soliciting a death warrant” (Nyanzi-Wakholi et al., 2009: 903). ART was preferred over traditional herbal treatment because it had clear dosages, expiry dates and was scientifically manufactured. ART was described as restoring physical health allowing patients to resume their daily activities. Men deliberately postponed accessing HIV testing until they were evidently sick. “Participants commended pre- and post-test counseling for enabling them to accept their status, cope with depression, stigma and thoughts of death… They emphasized the need for counseling to be continuous and not a one time event” (Nyanzi-Wakholi et al., 2009: 905).
10. Availability of HIV testing and counseling on-site at workplaces may increase uptake of HTC.
A cluster-randomized trial in Zimbabwe found that businesses randomized to on-site rapid HIV testing at their occupational clinic greatly increased uptake of VCT compared to vouchers for off-site VCT. Over 51% or 1,957 of 3,950 employees randomized to on-site testing had VCT compared to 19% or 586 of 3,532 employees randomized to off-site testing. Of those randomized to VCT though on site rapid testing, 88% were men; 12% were women. Of those randomized to VCT through off-site vouchers, 86% were men, 12% were women. Rapid testing was linked to basic HIV care which did not include antiretroviral therapy.
Between 2001 and 2007, 9,723 adults were tested for HIV in 14 Heineken company sites in Democratic Republic of Congo, Rwanda, Burundi, Republic of Congo, and Nigeria. Coverage was higher among female (28%) compared to male employees (22%) and higher among female spouses (18%) compared to 6% of male spouses, with spouses harder to reach than employees. VCT was made freely available at company sites. The median CD4 count of newly diagnosed persons rose significantly over the years, from 227 cells/ul in the first year to 316 cells/cubic mm in the fifth year. Each year an estimated 20% of the target population was tested for HIV through VCT. Of the 370 people found to be HIV-positive, 239 had started HAART by 2008. Initially employees were encouraged just to get tested; more recent policy has been to test every two years.