HIV This Week

Kawichai S, Celentano DD, Chariyalertsak S, Visrutaratna S, Short O, Ruangyuttikarn C, Chariyalertsak C, Genberg B, Beyrer C. Community-based Voluntary Counseling and Testing Services in Rural Communities of Chiang Mai Province, Northern Thailand. AIDS Behav 2007 Sep;11(5):770-7

Between September, 2002 to May, 2003, Kawichai and colleagues implemented community-based HIV Voluntary Counselling and Testing (VCT) services in four rural areas of Chiang Mai Province. The services included providing AIDS education and free mobile VCT using rapid testing with same day results. Overall, 427 villagers came for VCT (testers) and consented to be interviewed. HIV prevalence among testers was 4.9%, range from 1.1 to 8.4% by area. ‘It is free’ and/or ‘convenient’ were the most frequently cited factors that motivated them to get tested (72%) from our mobile VCT. Rural residents came for VCT when logistical barriers were removed.  HIV prevalence among testers in some areas was high. Without extending HIV prevention efforts to population segments with less access to health care, the HIV problem in Thailand may re-emerge. Convenient and low-cost VCT may prove crucial for containing this HIV epidemic.

Editors’ note: Rural community-based HIV testing and counselling services can have good uptake it they are free, confidential and convenient. It is important to collect, analyse and publish data on the comparative costs of mobile testing services, including the home-based testing being carried out in Uganda and Kenya, to have a better idea of their relative merit.

The objectives of this study were to examine the determinants of uptake of voluntary counselling and testing (VCT) services, to assess changes in sexual risk behaviour following VCT, and to compare HIV incidence amongst testers and non-testers. This was a prospective population-based cohort study of adult men and women in the Manicaland province of eastern Zimbabwe. Demographic, socioeconomic, sexual behaviour and VCT utilization data were collected at baseline (1998-2000) and follow-up (3 years later). HIV status was determined by HIV-1 antibody detection. In addition to services provided by the government and non-governmental organizations, a mobile VCT clinic was available at study sites. Lifetime uptake of VCT increased from under 6% to 11% at follow-up. Age, increasing education and knowledge of HIV were associated with VCT uptake. Women who took a test were more likely to be HIV positive and to have greater HIV knowledge and fewer total lifetime partners. After controlling for demographic characteristics, sexual behaviour was not independently associated with VCT uptake. Women who tested positive reported increased consistent condom use in their regular partnerships. However, individuals who tested negative were more likely to adopt more risky behaviours in terms of numbers of partnerships in the last month, the last year and in concurrent partnerships. HIV incidence during follow-up did not differ between testers and non-testers. Motivation for VCT uptake was driven by knowledge and education rather than sexual risk. Increased sexual risk following receipt of a negative result may be a serious unintended consequence of VCT. It should be minimized with appropriate pre- and post-test counselling.

Editors’ note: These findings have been the subject of much discussion since they appeared. They suggest that sexual risk is not a strong motivator of decisions to get tested for HIV in this area of Zimbabwe and that there is a tendency to increase the number of sexual partners for those who do decide to get tested and are found negative. This has been seen in other settings in which people appear to interpret an HIV-negative result as evidence of some invulnerability. Community testing literacy programmes to accompany any offer of services are key to changing social norms around sexual behaviour, with access to HIV testing and counselling being the entry point to discussions in communities about the need for change and how to foster it.