HIV This Week

Chomba E, Allen S, Kanweka W, Tichacek A, Cox G, Shutes E, Zulu I, Kancheya N, Sinkala M, Stephenson R, Haworth A. Evolution of Couples’ Voluntary Counseling and Testing for HIV in Lusaka, Zambia. J Acquir Immune Defic Syndr 2008; 47(1):108-15.

Chomba and colleagues describe promotional strategies for couples’ voluntary HIV counselling and testing and demographic risk factors for couples in Lusaka, Zambia, where an estimated two thirds of new infections occur in cohabiting couples. Couples’ voluntary HIV counselling and testing attendance as a function of promotional strategies is described over a 6-year period. Cross-sectional analyses of risk factors associated with HIV in men, women, and couples are presented. Community workers recruited from couples seeking voluntary HIV counselling and testing promoted testing in their communities. Attendance dropped when community worker outreach ended, despite continued mass media advertisements. In Lusaka, 51% of 8500 cohabiting couples who sought HIV testing were concordant negative for HIV and 26% concordant positive; 23% of couples were serodiscordant (that is, had 1 HIV-positive partner/1 HIV-negative partner), with 11% HIV-positive man/HIV-negative woman and 12% HIV-negative man/HIV-positive woman. HIV infection was associated with men’s age 30 to 39, women’s age 25 to 34, duration of union <3 years, and number of children <2. Even among couples with only 1-2 or no risk factors, HIV prevalence was 45% and 29%, respectively. Many married African adult couples do not have high-risk profiles, nor do they realize that one of the partners may have HIV. Active and sustained promotion is needed to encourage all couples to be jointly tested and counselled.

Editors’ note: This study highlights the importance of knowing your epidemic and tailoring effective responses to it. In mature HIV epidemics such as this one, as much as two-thirds of all HIV transmission is occurring within cohabiting couples. Serodiscordant couples have an HIV prevalence of 50% in their marital bed of which they may be unaware. Community mobilisation to create new social norms around knowledge of serostatus and the advantages of joint testing can provide couples with the opportunity to learn how they can prevent HIV from entering, or being transmitted within, their couple, while linking those already infected to treatment and support services. This study focused on couples seeking testing but home-based testing outreach in the community can achieve very high uptake with few negative social consequences if communities are engaged in the design, conduct, and evaluation of such programmes.

Prost and colleagues explore the feasibility and acceptability of translating a successful voluntary counselling and testing service model from Kenya to African communities in London. The authors conducted a qualitative study with focus group discussions and a structured workshop with key informants. Five focus group discussions were conducted in London with 42 participants from 14 African countries between August 2006 and January 2007. A workshop was held with 28 key informants. Transcripts from the group discussions and workshop were analysed for recurrent themes. Participants indicated that a community-based HIV voluntary counselling and testing service would be acceptable to African communities in London, but also identified barriers to uptake: HIV-related stigma, concerns about confidentiality, and doubts about the ability of community-based services to maintain professional standards of care. Workshop participants highlighted three key requirements to ensure feasibility: (a) efficient referrals to sexual health services for the newly diagnosed; (b) a locally appropriate testing algorithm and quality assurance scheme; (c) a training programme for voluntary counselling and testing counsellors. In conclusion, offering a community-based voluntary counselling and testing with rapid HIV tests appears feasible within a UK context and acceptable to African communities in London, provided that clients’ confidentiality is ensured and appropriate support is given to the newly diagnosed. However, the persistence of concerns related to HIV-related stigma among African communities suggests that routine opt-out testing in healthcare settings may also constitute an effective approach to reducing the proportion of late diagnoses in this group. HIV service models and programmes from Africa constitute a valuable knowledge base for innovative interventions in other settings, including developed countries.

Editors’ note: Provider-initiated testing and counselling can reduce the proportion of late diagnoses among African communities in cities such as London but it does not address the issue of HIV-related stigma. Research such as this, working with communities to identify barriers and facilitators of feasibility and acceptance, is key to ensuring that community-based testing increases knowledge of serostatus in a supportive environment.