Sherr L, Lopman B, Kakowa M, et al. Voluntary counseling and testing: Uptake, impact on sexual behavior, and HIV incidence in a rural Zimbabwean cohort. AIDS 2007;21:851-60
To examine the factors that determine uptake of voluntary counseling and testing (VCT) services, changes in sexual risk behavior following VCT, and HIV incidence rates among people who become tested for HIV and those who do not
A prospective, population-based cohort study of adult men and women, with baseline data collected between 1998 and 2000 and follow-up data collected 3 years later.
Four subsistence farming areas; two roadside trading centers; four forestry, tea, and coffee estates; and two small towns in the rural province of Manicaland in eastern Zimbabwe
All local residents enumerated in a household census between July 1998 and February 2000. One member of each marital group was selected for the cohort.
Seventy-nine percent (9454/11980) of people who were eligible at baseline participated; 6259 men aged 17-54 years and women aged 15-44 years reported sexual experience at follow-up and are included in the cross-sectional analysis. Analyzed for changes in sexual behavior and HIV incidence over time were 5775 individuals who participated at baseline and follow-up.
At baseline and follow-up, data were collected on demographics, socioeconomic characteristics, HIV knowledge, and sexual behavior through an interviewer-led questionnaire. Dried blood spots were collected for anonymous HIV serological testing. In parallel with the data collection, free VCT and free treatment for sexually transmitted infections (STIs) were made available in the study areas through mobile clinics. At baseline, respondents were asked whether and when they had ever received a test for HIV (VCT, aside from the dried blood spot testing collected for the study); how long ago they were last tested; the reasons for being tested; the factors that deterred them from testing; and whether they knew the HIV infection status of their partner. At follow-up, additional questions were asked about whether HIV test results were collected and whether counseling was received before and/or after they were given their HIV test results.
The primary outcomes are subsequent sexual behavior and incidence of HIV after VCT uptake.
At baseline, few study participants had ever received VCT (6.6%). Pre-test counseling at the mobile VCT clinic was taken up by 5.9% of participants, but only 2.0% returned to receive their results. Prevalence of HIV among research participants who took up VCT was 21.5%, compared with 22.5% among all other participants. At follow-up, 19% reported having had an HIV test in the past, with men being significantly more likely to have been tested (26% men, 14% women, p<0.001) but less likely to have returned for the results (46% men, 71% women, p<0.001). Only 11% knew their HIV status at follow-up. Of the 1185 people who tested for HIV, 51% reported having received pre-test counseling. For both men and women, those who received pre-test counseling were significantly more likely to return for their results than those who did not (men: 82% vs. 21%; women: 80% vs. 53%; p<0.001 for both groups). Psychological factors were the most commonly cited deterrent (32%) to getting an HIV test. Secondary/higher education was a predictor of testing in younger groups (<35 years of age) and older adults (≥45 years of age) but not in people aged 35-44 years. Men and women who received a positive test result and post-test counseling had fewer sexual partners in the year prior to follow-up, and women, whether they received counseling or not, reported higher levels of condom use in their regular partnerships. On the other hand, individuals who received a negative result and counseling became riskier: with more new partners and more concurrent partnerships in the last year and more frequent beer hall attendance. HIV incidence in men and women who reported a negative HIV test at or near baseline did not differ significantly from those who did not report a test at baseline.
The authors conclude that motivation for VCT uptake was driven by knowledge and education rather than by sexual risk. Increased sexual risk following receipt of a negative test result may be a serious, unintended consequence of VCT that should be minimized with appropriate pre- and post-test counseling.
Based on the Newcastle-Ottawa scale for rating cohort studies, this study is of good quality. The cohort consisted of a representative sample of the population; however, because participants who decided to take up VCT were a self-selected group within the larger cohort, it is difficult to generalize the role of VCT were it to be extended widely. VCT, offered along with treatment of STIs, was a part of the research program, which may have influenced who accessed testing, thus limiting the external validity of the findings. In addition, the VCT mobile clinics were present in communities at the time that surveys were being conducted. This short period of time may have hindered access to the services.
In this study, the provision of VCT by mobile clinics based where people have to give a sample specifically for personalized HIV testing was not adequate to effect wide uptake of services in a 3-year period. Although 88% of participants said they wanted to know their HIV status, only 11% had done so by follow-up. This result is counter to the results from a home-based VCT program in Uganda and mobile same-day VCT in other areas in Zimbabwe, which have demonstrated high rates of VCT uptake.(1, 2) The results from this study show that people who are the most risk-averse are taking up VCT, and in this particular population, VCT has become part of risk-averse behavior, as demonstrated by findings in other studies done in Africa.(3, 4) Because this study was conducted at a time when antiretroviral therapy was not available in Zimbabwe, motivation for testing and establishing one's HIV status may have been lower than in settings where therapy is available.
This study suggests that the provision of VCT must be given serious attention to ensure that all groups, specifically those that practice risky behaviors, access the services. In addition, post-test counseling education for HIV-negative individuals must stress the importance of staying negative by practicing safe behaviors. It is hoped that such education will result in maintaining and encouraging less risky behaviors among people who receive HIV-negative results.
- Matovu JK, Kigozi G, Nalugoda F, Wabwire-Mangen F, Gray RH. The Rakai Project counselling programme experience. Trop Med Int Health 2002;7:1064-7.
- Shetty AK, Mhazo M, Moyo S, et al. The feasibility of voluntary counselling and HIV testing for pregnant women using community volunteers in Zimbabwe. Int J STD AIDS 2005;16:755-9.
- Gage AJ, Ali D. Factors associated with self-reported HIV testing among men in Uganda. AIDS Care 2005;17:153-65.
- 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;33:165-70.