Promotion of couples’ voluntary counseling and testing
Principal Investigator: Susan Allen, M.D., M.P.H., DTM&H,
Professor of Global Health
Location: Lusaka, Zambia and Kigali, Rwanda
Funding Agency: National Institutes of
Mental Health (NIMH)
PROGRESS REPORT FISCAL YEAR 3: JUNE 2004-MAY 2005
Sub-Saharan Africa has over 80% of the world’s HIV infections, and
an estimated 70% of prevalent and incident infections in African
cities are the result of transmission between married partners. Our
research team has 15 years’ experience conducting heterosexual HIV
prevention research in the capitals of two African countries:
Kigali, Rwanda (1986) and Lusaka, Zambia (1994). Our early studies
in Rwanda showed that voluntary HIV counseling and testing
(VCT) results in pronounced risk reduction in married couples. Since
we first published these findings in 1991, we have provided VCT to
over 20,000 Rwandan and Zambian couples. In the last year we have
couples’ VCT in antenatal care clinics in
order to combine prevention of mother-to-child transmission and
heterosexual HIV transmission.
Couples’ VCT is the only prevention
program proven to reduce HIV incidence in the largest risk group in
the world, African couples. It is also feasible, cost-effective, and
popular with clients. In spite of this, in 2002, twenty years after
the start of the HIV epidemic, ten years after the first publication
about couples’ VCT
in Africa and three years after the discovery of inexpensive
regimens for perinatal HIV prevention, VCT has been provided to < 1
% of African couples. A number of structural factors affect
demand for and supply of couples’ VCT.
Demand for couples’ VCT is low,
because of the belief that monogamy is ‘safe’, the fear of stigma,
gender inequity between husband and wife, and lack of knowledge
about where VCT can be obtained. Given the low demand, policymakers
and other influential groups have not promoted couples’ VCT. In
turn, funding agencies have not supported VCT services, further
compromising supply and ensuring low utilization. Given what we know
about the beneficial impact of couples’ VCT, it is critical that
this continuing cycle of low demand low supply be interrupted.
We propose three linked activities in each of two capital cities in
Africa: a) a three-armed study of community based interventions to
increase couples’ Voluntary HIV
counseling and testing (specific aims 3 and 4); b) follow-up
behavioral assessments of structural factors in HIV discordant
couples, with the goal of improving couple counseling strategies
(specific aim 5); and c) systematic inclusion of community influence
networks, policymakers, and funding agencies in the development and
implementation of the interventions, a process that will culminate
in a plan and commitment for sustainability and dissemination of
couples’ VCT (specific aims 1,2,
Most HIV transmission in African cities now occurs in cohabiting
couples. Our experience with >20,000 couples in Rwanda and Zambia
confirms that when husbands and wives are HIV tested and counseled
together, HIV/STD rates decrease by >50%. Although this has been
known for more than a decade, access to HIV testing remains limited
even in urban centers and existing Voluntary HIV Counseling and
Testing (VCT) programs rarely cater to couples. A number of
structural factors affect demand for and supply of couples’ VCT.
Demand for couples’ VCT is low because of the belief that monogamy
is ‘safe’, the fear of stigma, gender inequity between husband and
wife, and lack of knowledge about where VCT can be obtained. Given
the low demand, policymakers and other influential groups have not
promoted couples’ VCT. In turn, funding agencies have not supported
VCT services, further compromising supply and ensuring low
utilization. Given what we know about the beneficial impact of
couples’ VCT, it is critical that this continuing cycle of low
demand-low supply be interrupted. We propose a quasi-experimental
3-armed study with a cross-over design, to compare two interventions
designed to overcome demand and supply structural barriers and
increase the number of couples receiving VCT in two African capital
cities. Sustainability of successful interventions will be assured
through formal partnerships with influence networks, policymakers,
and funding agencies.
HIV seroconversion rates in discordant couples (who make up 20% of
couples in Lusaka and 10% in Kigali) decrease from an estimated 23%
to 8% per year after VCT. Although this is good, the rate could be
further decreased if barriers to risk reduction were better
understood. Psychosocial and structural variables associated with
keeping appointments, condom use, and biological measures of risk
reduction will be assessed through follow-up of HIV discordant
couples. The findings will be used to improve couples’ counseling
procedures and develop training materials for use in high prevalence
Year one: to identify and characterize neighborhoods and
stakeholders in Kigali, Rwanda and Lusaka, Zambia.
Sponsor a two-day conference in each city bringing together
100-125 policymakers, funding agency representatives, and
potential influence networks.
Identify appropriate influence agents, such as church leaders,
government and non-governmental medical clinic staff, community
health workers, blood bank recruiters, PTA and market association
members, and public transport drivers.
Conduct key informant interviews with government policymakers and
international, bilateral, and non-governmental funding agencies,
and establish their role as stakeholders.
Map the location, utilization, service capacity, and level of
expertise of facilities that provide VCT.
Identify three comparable neighborhoods in each city suitable for
the proposed intervention trial.
Year one: to secure cooperation from influence networks (4 per
intervention arm) and their VCT promotion agents (20 per network),
and to develop the content and procedures for the interventions
described in Aim 3.
Negotiate and finalize a Memorandum of Participation with
influence network agents.
Involve agents in the adaptation of existing training curricula
and development of procedures specific to each context.
Upgrade the capacities of existing VCT facilities in the
neighborhoods selected for the trial, to ensure accessibility of
standardized same-day couples’ VCT services.
Develop and begin implementation of a plan for future
sustainability with influence networks.
Years two to four: to assess the impact of two community-oriented
interventions that increase couples VCT using a quasi-experimental
cross-over study design. Kigali and Lusaka will each have one
‘usual practice’ control neighborhood with a VCT center but no
promotional activities. An average of 25 couples/month will seek
VCT in each ‘usual practice’ neighborhood. In each city, two
intervention neighborhoods will have a ‘promote demand for VCT’
intervention, in which influence agents will distribute written
invitations for couples’ VCT continuously throughout the 36 months
of the trial. In the first 18 months, a mobile VCT team will
‘enhance supply’ in one of the two ‘promote demand’ neighborhoods.
This unit will move to the other ‘promote demand’ intervention
neighborhood for the second 18 months, in a ‘cross-over’ design.
This will allow us to test three hypotheses:
H1: Promoting couples VCT through influence networks will more
than double the number of couples who request VCT at existing
facilities (‘promote demand alone’ vs.’ usual practice’).
H2: Enhancing supply by providing ‘mobile’ VCT services at
accessible neighborhood locations will result in a doubling of the
proportion of invited couples that receive VCT (‘promote demand
plus enhance supply’ vs. ‘promote demand alone’).
H3: There will not be appreciable secular trends in the ‘usual
practice’ neighborhood, and the interventions will yield similar
results whether they take place during the first 18 months
compared with the second 18 months (‘before cross-over vs. after
Years two to four: to compare the volume of written invitations
and the response rate in each influence network, and to examine
the structural variables that may influence these outcomes
including the city, time and place of the invitation, whether the
issuing of the written invitation was preceded by a public
endorsement and whether the invitation was given to the husband,
wife, or couple. In addition to descriptive analyses, we will test
H4: Certain influence network agents will distribute a larger
number of couples VCT invitations than others (ranging from
minimum 100 to maximum 200/agent).
H5: The response rate per 100 invitations will differ between
networks, ranging from 5% to 20% with the ‘promote demand’
intervention, and from 10% to 40% with the ‘promote demand plus
enhance supply’ intervention.
Years one to five, to identify psychosocial and structural
determinants of regular follow-up, condom use, and biological
markers of the lack of unprotected sex in HIV discordant couples.
Examine gender roles, relationship intimacy and alcohol use as
predictors of these outcomes.
Model HIV specific couple communication as a mediator of the above
Analyze these effects separately for husbands and wives and
examine the concordance in partners’ responses.
Examine differences specific to couples in Zambia and Rwanda.
Years one to five: to ensure that study efforts result in
sustainable couples’ VCT programs, ongoing work will focus on
inclusion of policymakers and funding agencies on a regular basis.
Provide a formal liaison between the research team and influence
agents on one hand, and the policymakers and funding agencies on
the other: Dr Michel Carael will spend one month each year in each
city as senior scientist-ambassador.
Provide annual updates to policymakers and funding agency
representatives in the form of progress reports/executive
summaries, conference presentations, and invitations to observe
work in the field.
In year five, sponsor a conference in each city for influence
agents, policymakers and funding agencies with the intended
outcome of formalizing the commitment to an action plan for
funding and political support to assure continuation and expansion
of couples’ VCT.
PROGRESS REPORT FISCAL YEAR 3: JUNE 2004-MAY 2005