What Works—HIV Testing and Counseling for Women

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 cross-sectional and nationally representative study from 2004 to 2005 in Uganda of 1,092 HIV-positive people, 64% female, from a 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 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 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”.

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 fro 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.

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.” 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.

Among 7,400 patients between 2006 and January 2008 in a Malawian STI clinic who had not yet had an HIV test were offered VCT, of whom 49.6% accepted. Uptake was higher among males (51.5% for men compared to 48.3% for women). Including those reporting a previous positive result, overall HIV prevalence was 41%: 43% among women and 38% among men.

A program in Nigeria found that although free HIV testing is available in ANC, most women refuse to test in ANC settings due to issues of confidentiality related to their husbands, along with lack of HIV treatment options. When VCT is offered in primary health care posts for treatment of malaria in children, women who had not previously tested for HIV were more likely to test.

At a provincial hospital in Mombasa, Kenya, HIV testing and counseling were offered to women bringing their child for immunization or acute care services. Most women said HIV testing should be offered in these clinics (472/493, 95.7%), with many citing the benefits of regular testing and entry to prevent mother-to-child transmission. Of 500 women, 416 (83.4%) received test results, 97.6% on the same day. After 50 participants, point-of-care testing replaced laboratory-based rapid testing. Uptake increased 2.6 times with point-of-care testing. Of 124 women who had not accessed HIV testing during pregnancy, 98 tested in the study (79.0%) . (Abstract)

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.

A mass media campaign in Zimbabwe disseminated via TV, radio and print that encouraged heterosexual couples to access VCT increased the proportion of couples accessing VCT significantly. Comparison of routine clinic data between the proportion of couples attending VCT before and after the launch of the campaign found that couples accessing VCT increased from 13% in 2005 to 18% in 2007. Survey data showed that individuals with exposure to the campaign were more likely to access VCT than those without exposure to the campaign.

A study from 2002 to 2003 in rural Thailand with people above age 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/AIDS 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.

A 2006 and still ongoing study until 2011 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 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.” 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.

A randomized controlled trial in Thailand found that mobile VCT offered at no cost in community public settings along with entertainment and education increased VCT uptake. VCT uptake increased from 18 to 25 people per day. The median age of those accessing VCT decreased from 38 to 35 years of age. Between February 2007 and December 2008, 6,996 people accessed VCT with 1.6% testing HIV-positive . (Abstract)

A six-week awareness campaign in six rural villages in Tanzania that was evaluated by a randomly selected pre-post household survey for 120 households and VCT monitoring data found that mobile VCT resulted in the direct testing of 1,116 people, 54.5% male or 6.7% of the total adult population in the villages, with a significant increase in community members reporting having ever been tested for the first time . (Abstract)

Between June and December 2007, mobile VCT in a rural area in Zambia with no health facilities coupled with drama performances to create awareness and used tents for counseling rooms, resulting in 2,487 people accessing VCT, of whom 1,167 were women. Of 290 people testing positive (an 11.6% incidence rate), 179 were female and 190 were referred for services . (Abstract)

A project in Kenya using community mobilization resulted in reaching over 127,000 people with HIV prevention information out of which over 42% were counseled and testing. Of these, 2,630 were found HIV-positive and were referred for care while HIV-negative people were counseled on risk reduction . (Abstract)

Community outreach and mobilization through youth peers who go door to door, using speakers on cars to encourage VCT, dissemination of information and discussions at community events in rural South Africa resulted in increased numbers of youth accessing VCT services . (Abstract)

An HIV/AIDS hotline was introduced in Egypt, resulting in over 145,000 calls, where more than 75% were by men. Data at VCT sites demonstrated that about 20% of clients had been referred by the hotline . (Abstract)

An analysis of a non-randomized study from rural Southwestern Uganda with 1869 participants (Wolff et al. 2005) found “very high acceptability and uptake of VCT results when testing and or results were given at home compared to the standard (facility)” . 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 (Bateganya et al., 2007).

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.

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%.

A study nested in a cluster randomized trial in Uganda which compared home and clinic-based methods of HIV testing for family members of HIV-positive patients found that those reached at home were more likely to be tested for HIV. Of a total of 7,184 household members, 3,974 (55% female) were reached at home. Assuming HIV prevalence of 7%, 56% of HIV-positive household members were identified at home compared to 27% in the clinic. HIV-positive patients were given free HIV testing vouchers and encouraged to invite members of their household to the clinic; or people were visited at home. Of 148 spouses of HIV-positive clients getting treated, 47% were HIV-negative.

A study in Kampala, Uganda from October 2005 to October 2007 indentified many otherwise undiagnosed HIV-positive adults through home-based testing that was conducted if index clients had disclosed their serostatus to a household member, consented to the visit, or requested counselor-assisted disclosure. Of 4,662 household members visited, 90% agreed to VCT. Of the index clients, 75% were female. HIV prevalence was 19% among adults as compared to the Kampala average as per the 2004/2005 HIV/AIDS Sero-Behavioral survey. Prevalence was higher among women (21%) as compared to men (14%). Same day results were given using Determine for screening, Statpak for confirmatory and Unigold for a tie- breaker . (Abstract)

Four hundred community mobilizers and 75 trained counselors going house to house in rural western Kenya increased counseling and testing. Using handheld computers, census data was recorded, whether household entry was allowed, consent for testing, age, sex, and HIV test results. Those consenting who were above age 12 were counseled and tested. The door to door census found 8,999 households containing 35,976 people, of whom 52% were women. All but 13 allowed entry. Only 24% had previously had an HIV test. Of 19,034 counseled, 18,229 had HIV tests. All who tested positive were referred for care; those who tested HIV-negative were counseled on lowering risk behaviors . (Abstract)

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”.

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..

An intervention in one district in **Uganda** in which 35 VCT volunteer couples were oriented on couple dialogue techniques to avert gender based violence and who subsequently counseled an additional 206 couples greatly increased the numbers of couples who were willing to know their HIV status. VCT volunteers from eight civil society organizations were trained in rights based community mobilization approaches to preventing violence and skills to integrate GBV interventions into VCT services. In 2006 and 2007, out of 206 couples that were counseled in the GBV intervention area, all received their HIV test results. In comparison, 5% of 8,708 couples that received HIV counseling and testing service in the non-GBV intervention area received their test results. Couples were ten times more likely to receive results in GBV intervention areas than in non-GBV intervention areas . (Abstract)

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” . 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).

A study of ten comparable small and medium scale enterprises was split into two matched groups of five each in Nigeria. One group of companies recruited, trained and deployed a person each who was living openly with HIV. Each of the ten enterprises nominated and trained two peer educators who conducted regular peer education sessions. After six months, the companies that had VCT promoted by a person living with HIV had four times the number of staff accessing VCT compared to those that did not (no numbers given).

A CD with taped testimonies of women who tested HIV-positive was shown in 21 clinics in Mexico. Of the 1,869 women who tested in a ten-week period, 60% said they were motivated to access HIV testing because of the taped testimonies of other women.

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.

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 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.

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 . Alcohol users are more likely to perpetrate intimate partner violence. [See also Chapter 11B. 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. (Mackenzie et al., 2008).

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.

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 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.