Promotion of couples' voluntary counselling and testing for HIV through influential networks in two African capital cities

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Abstract

Background

Most new HIV infections in Africa are acquired from cohabiting heterosexual partners. Couples' Voluntary Counselling and Testing (CVCT) is an effective prevention strategy for this group. We present our experience with a community-based program for the promotion of CVCT in Kigali, Rwanda and Lusaka, Zambia.

Methods

Influence Network Agents (INAs) from the health, religious, non-governmental, and private sectors were trained to invite couples for CVCT. Predictors of successful promotion were identified using a multi-level hierarchical analysis.

Results

In 4 months, 9,900 invitations were distributed by 61 INAs, with 1,411 (14.3%) couples requesting CVCT. INAs in Rwanda distributed fewer invitations (2,680 vs. 7,220) and had higher response rates (26.9% vs. 9.6%), than INAs in Zambia. Context of the invitation event, including a discreet location such as the INA's home (OR 3.3–3.4), delivery of the invitation to both partners in the couple (OR 1.6–1.7) or to someone known to the INA (OR 1.7–1.8), and use of public endorsement (OR 1.7–1.8) were stronger predictors of success than INA or couple-level characteristics.

Conclusion

Predictors of successful CVCT promotion included strategies that can be easily implemented in Africa. As new resources become available for Africans with HIV, CVCT should be broadly implemented as a point of entry for prevention, care and support.

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Most cited references 48

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Effect of serotesting with counselling on condom use and seroconversion among HIV discordant couples in Africa.

J. Bogaerts, A Serufilira, P Van de perre … (1992)

To determine whether HIV testing and counselling increased condom use and decreased heterosexual transmission of HIV in discordant couples. Prospective study. Kigali, the capital of Rwanda. Cohabiting couples with discordant HIV serology results. Condom use in the couple and HIV seroconversion in the negative partners. 60 HIV discordant couples were identified, of whom 53 were followed for an average of 2.2 years. The proportion of discordant couples using condoms increased from 4% to 57% after one year of follow up. During follow up two of the 23 HIV negative men and six of the 30 HIV negative women seroconverted (seroconversion rates of 4 and 9 per 100 person years). The rate among women was less than half that estimated for similar women in discordant couples whose partners had not been serotested. Condom use was less common among those who seroconverted (100% v 5%, p = 0.01 in men; 67% v 25%, p = 0.14 in women). Roughly one in seven cohabiting couples in Kigali have discordant HIV serological results. Confidential HIV serotesting with counselling caused a large increase in condom use and was associated with a lower rate of new HIV infections. HIV testing is a promising intervention for preventing the spread of HIV in African cities.

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Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania.

M Sweat, S Gregorich, G Sangiwa … (2000)

Access to HIV-1 voluntary counselling and testing (VCT) is severely limited in less-developed countries. We undertook a multisite trial of HIV-1 VCT to assess its impact, cost, and cost-effectiveness in less-developed country settings. The cost-effectiveness of HIV-1 VCT was estimated for a hypothetical cohort of 10000 people seeking VCT in urban east Africa. Outcomes were modelled based on results from a randomised controlled trial of HIV-1 VCT in Tanzania and Kenya. Our main outcome measures included programme cost, number of HIV-1 infections averted, cost per HIV-1 infection averted, and cost per disability-adjusted life-year (DALY) saved. We also modelled the impact of targeting VCT by HIV-1 prevalence of the client population, and the proportion of clients who receive VCT as a couple compared with as individuals. Sensitivity analysis was done on all model parameters. HIV-1 VCT was estimated to avert 1104 HIV-1 infections in Kenya and 895 in Tanzania during the subsequent year. The cost per HIV-1 infection averted was US$249 and $346, respectively, and the cost per DALY saved was $12.77 and $17.78. The intervention was most cost-effective for HIV-1-infected people and those who received VCT as a couple. The cost-effectiveness of VCT was robust, with a range for the average cost per DALY saved of $5.16-27.36 in Kenya, and $6.58-45.03 in Tanzania. Analysis of targeting showed that increasing the proportion of couples to 70% reduces the cost per DALY saved to $10.71 in Kenya and $13.39 in Tanzania, and that targeting a population with HIV-1 prevalence of 45% decreased the cost per DALY saved to $8.36 in Kenya and $11.74 in Tanzania. HIV-1 VCT is highly cost-effective in urban east African settings, but slightly less so than interventions such as improvement of sexually transmitted disease services and universal provision of nevirapine to pregnant women in high-prevalence settings. With the targeting of VCT to populations with high HIV-1 prevalence and couples the cost-effectiveness of VCT is improved significantly.

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Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners.

A. Kamali Asl, Alexander J. Whitworth, S S Malamba … (1999)

To assess the efficacy of transmission of HIV-1 within married couples in rural Uganda according to the sero-status of the partners. Estimation of HIV incidence rates for 2200 adults in a population cohort followed for 7 years comparing male-to-female with female-to-male transmission and sero-discordant with concordant sero-negative couples. Each year, adults (over 12 years of age) resident in the study area were linked to their spouses if also censused as resident. The HIV sero-status was determined annually. At baseline 7% of married adults were in sero-discordant marriages and in half of these the man was HIV-positive. Among those with HIV-positive spouses, the age-adjusted HIV incidence in women was twice that of men (rate ratio (RR) = 2.2 95% confidence interval (CI) 0.9-5.4) whereas, among those with HIV-negative spouses, the incidence in women was less than half that of men (RR = 0.4, 95% CI 0.2-0.8). The age-adjusted incidence among women with HIV-positive spouses was 105.8 times (95% CI 33.6-332.7) that of women with HIV-negative spouses, the equivalent ratio for men being 11.6 (95% CI 5.8-23.4). Men are twice as likely as women to bring HIV infection into a marriage, presumably through extra-marital sexual behaviour. Within sero-discordant marriages women become infected twice as fast as men, probably because of increased biological susceptibility. Married adults, particularly women, with HIV-positive spouses are at very high risk of HIV infection. Married couples in this population should be encouraged to attend for HIV counselling together so that sero-discordant couples can be identified and advised accordingly.

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Author and article information

Journal

Journal ID (nlm-ta): BMC Public Health

Title: BMC Public Health

Publisher: BioMed Central

ISSN (Electronic): 1471-2458

Publication date Collection: 2007

Publication date (Electronic): 11 December 2007

Volume: 7

Page: 349

Affiliations

[1 ]The Rwanda-Zambia HIV Research Group, 1520 Clifton Road, Emory University, Atlanta, GA 30322, USA

[2 ]Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322, USA

[3 ]University Teaching Hospital, Lusaka, Zambia

[4 ]Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, 1530 3 ^rdAve S., Birmingham, AL 35294-0022, USA

[5 ]Department of Public Health Education, University of North Carolina at Greensboro, 437 HHP Building, Greensboro, NC 27402-6170, USA

[6 ]Department of Pediatrics, School of Medicine, University of Southern California, 4650 Sunset Blvd., CHLA MS 30, Los Angeles, CA 90027, USA

[7 ]School of Medicine, Harvard University, 25 Shattuck Street, Boston, MA 02115, USA

[8 ]Lusaka Urban District Health Management Team, Makishi Road, PO Box 50827, Lusaka, Zambia

[9 ]Monitoring and Evaluation Unit, UNAIDS, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland

[10 ]Counseling Services Unit, Ministry of Health, PO Box 30205, Lusaka, Zambia

Article

Publisher ID: 1471-2458-7-349

DOI: 10.1186/1471-2458-7-349

PMC ID: 2241615

PubMed ID: 18072974

SO-VID: ed8845da-e617-45ba-9869-109aecfe55f8

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Promotion of couples' voluntary counselling and testing for HIV through influential networks in two African capital cities

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HIV Self-Testing

Most cited references 48

Effect of serotesting with counselling on condom use and seroconversion among HIV discordant couples in Africa.

Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania.

Rates of HIV-1 transmission within marriage in rural Uganda in relation to the HIV sero-status of the partners.

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