Sherr L, Lopman B, Kakowa M, Dube S, Chawira G, Nyamukapa C, Oberzaucher N, Cremin I, Gregson S. Voluntary counselling and testing: uptake, impact on sexual behaviour, and HIV incidence in a rural Zimbabwean cohort. AIDS 2007 Apr 23;21(7):851-860.
To examine the determinants of uptake of voluntary counseling and testing (VCT) services, to assess changes in sexual risk behavior following VCT, and to compare HIV incidence amongst testers and non-testers.
Prospective population-based cohort study of adult men and women.
Manicaland province of eastern Zimbabwe, which contains subsistence farming areas, roadside trading areas, small towns, and forestry, tea, and coffee estates.
The cohort is part of the Manicaland HIV/STD Prevention Project, in which all local residents were enumerated, first in a baseline household census conducted from July 1998 to February 2000, and again three years later (referred to as the follow-up survey). Information on demographic and socioeconomic characteristics, HIV knowledge, and sexual behavior were collected. Responses to sensitive questions about sexual behavior were collected using an informal confidential system of voting. Dried blood spots were collected for HIV serological testing, which was performed using a highly sensitive and specific antibody dipstick assay. In parallel with the research, free HIV counseling and testing and free treatment for other sexually transmitted diseases were made available in the study areas through a mobile clinic service. The 12 sites were enumerated in succession with the mobile VCT clinic present within the study site at the time the survey was being conducted. Nine counselors used a systemic approach that emphasized the background of the client and tailored pre- and post-test counseling accordingly. VCT services provided primarily by non-governmental organizations were also available in the study areas and the provincial capital Mutare.
The study populations were males aged 17 to 54 years and females aged 15 to 44 years. The overall participation rate of individuals eligible for the cohort study was 79% at baseline (9,454/11,980) and 79% at follow-up (7,019/8,894). A total of 6,259 individuals (61% female) reported sexual experience at follow-up and were therefore included in the cross-sectional analysis. Of these, 5,775 individuals who participated in the baseline and follow-up study were analyzed for sexual behavior change and HIV incidence.
The primary outcomes were HIV incidence, HIV prevalence, and uptake of VCT.
HIV prevalence based on the undisclosed dipstick tests used in the survey was 20% and 18% for males and 26% and 22% for females at baseline and follow-up, respectively. At baseline, few study participants had ever received VCT (6.6%). At follow-up, 19% reported having had an HIV test at some point in the past, with males being significantly more likely to have been tested (26% males versus 14% females, p<0.001), but less likely to have received the result after testing (46% males versus 71% females, p<0.001). Consequently, 12% of men and 10% of women in the study population had ever collected an HIV test result. The great majority of respondents (88%) said they wanted to know if they were HIV-infected. Of the 1,185 who had tested for HIV, 51% reported having received pre-test counseling. For both males and females, those who received pre-test counseling were significantly more likely to return for their results than those who did not (males: 82% versus 21%; females: 80% versus 53%; p<0.001). Psychological factors were the most common deterrent for testing (32%), followed by stigma and discrimination (8%) and the belief that knowledge of infection would accelerate disease progression (7%). For both sexes, increasing age was strongly associated with VCT uptake. Men who were tested (compared to those who were not tested) were less likely to live in roadside trading centers (OR 0.36, p<0.05) and reported more partners (OR 2.08, p<0.001). Women who were tested were more likely to live in roadside centers (OR 2.07, p<0.01) and in subsistence farming areas (OR 2.02, p<0.01). Being HIV-infected (OR 1.33, p<0.01) and having greater knowledge about HIV/AIDS (OR 1.18, p<0.01) were predictors for VCT in women, but not in men. Having any secondary/higher education was a significant predictor of testing in both sexes in all ages except 35-44 (OR ~2, p-value not given). Men and women who received a positive result and post-test counseling had fewer sexual partners in the year prior to follow-up (age- and sex-adjusted OR 0.53, p<0.05) and women reported higher levels of condom use in their regular partnerships (AOR 0.11, where values <1 indicate consistent condom usage, p<0.05). Individuals who received a negative result and counseling were more likely to become risky in terms of beer hall attendance (AOR 1.45, p<0.1), new partners in the last year (AOR 1.34, p<0.1), and number of concurrent partnerships (AOR, 1.50, p<0.05). Individuals who received a negative result but no counseling were more risky in terms of partners in the last month (AOR, 1.51, p<0.01) and last year (AOR 1.31, p<0.05). HIV incidence in males and females who tested negative at or near baseline did not differ significantly from those who had not tested at/near baseline (17.5-23.1 cases per 1,000 person-years).
The authors conclude that motivation for VCT uptake was driven by knowledge of HIV and place of residence, rather than risk behavior. The slow uptake of VCT indicates that the provision of VCT by mobile clinics, based at the site where people have to give a sample specifically for personalized HIV testing, was not a sufficient mechanism to affect wide uptake of services in a three-year period. Increased sexual risk following receipt of a negative result may be a serious unintended consequence of VCT. Therefore, the authors suggest that such risks should be minimized with appropriate pre- and post-test counseling.
Based on the Newcastle-Ottawa rating system for observational cohorts, this study is of good quality. This study had a few limitations. For instance, the cohort accessing VCT was a self-selected group, thus making it difficult to generalize the role of VCT were it extended widely. The external validity of the study may also be limited, since VCT was offered in a research context. Additionally, the study was conducted at a time when antiretroviral therapy services were not available in Zimbabwe. This could have been a cause of low motivation for testing and establishing HIV status.
The findings in this study correlate to several findings in other research. First, the increased numbers of sexual partnerships found in individuals who tested HIV-negative in this study is analogous to literature from Western settings showing that those who attend for repeat HIV testing have elevated risk of HIV sero-conversion and have increased risk behaviors.(1,2) Second, the results of this study compare unfavorably with the high level of uptake in home-based VCT programs in Uganda and mobile same-day VCT in other parts of Zimbabwe.(3,4) Third, results from this study demonstrate that those most risk-averse are taking up VCT, which is also consistent with findings from other populations.(5,6)
VCT is becoming increasingly available in resource-poor settings. This study demonstrated that, although many people were interested in learning their HIV status, uptake of VCT was low and increased slowly. Psychological factors were found to play a critical role in the decision to test, both as deterrents to testing and in subsequent behavioral responses, and must be considered as VCT is expanded and uptake increases. The suggestion that testing negative was associated with increased risk behavior in terms of partner acquisition rates should be a concern. This unintended effect of VCT needs to be considered when planning services - in particular, post-test education - as well as in the design of behavior-change communication interventions. Since the majority of the population is not HIV-infected, even small population-level increases in risk behavior could have major implications.
- Norton J, Elford J, Sherr L, Miller R, Johnson MA. Repeat HIV testers at a London same-day testing clinic. AIDS 1997 May;11(6):773-81.
- Leaity S, Sherr L, Wells H, Evans A, Miller R, Johnson M, et al. Repeat HIV testing: high-risk behaviour or risk reduction strategy? AIDS 2000 Mar 31;14(5):547-52.
- Matovu JK, Kigozi G, Nalugoda F, Wabwire-Mangen F, Gray RH. The Rakai Project counselling programme experience. Trop Med Int Health 2002 Dec;7(12):1064-7.
- Shetty AK, Mhazo M, Moyo S, von Lieven A, Mateta P, Katzenstein DA, et al. The feasibility of voluntary counselling and HIV testing for pregnant women using community volunteers in Zimbabwe. Int J STD AIDS 2005 Nov;16(11):755-9.
- Gage AJ, Ali D. Factors associated with self-reported HIV testing among men in Uganda. AIDS Care 2005 Feb;17(2):153-65.
- Adewole DA, Lawoyin TO. Characteristics of volunteers and non-volunteers for voluntary counseling and HIV testing among unmarried male undergraduates. Afr J Med Med Sci 2004 Jun;33(2):165-70.