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Research Initiatives

Promotion of couples’ voluntary counseling and testing (CVCT)

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

ABSTRACT

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 implemented ‘same-day’ 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, and 6).

SPECIFIC AIMS

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 areas.

 

  1. Year one: to identify and characterize neighborhoods and stakeholders in Kigali, Rwanda and Lusaka, Zambia.

  1. Sponsor a two-day conference in each city bringing together 100-125 policymakers, funding agency representatives, and potential influence networks.

  2. 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.

  3. Conduct key informant interviews with government policymakers and international, bilateral, and non-governmental funding agencies, and establish their role as stakeholders.

  4. Map the location, utilization, service capacity, and level of expertise of facilities that provide VCT.

  5. Identify three comparable neighborhoods in each city suitable for the proposed intervention trial.

  1. 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.

  1. Negotiate and finalize a Memorandum of Participation with influence network agents.

  2. Involve agents in the adaptation of existing training curricula and development of procedures specific to each context.

  3. Upgrade the capacities of existing VCT facilities in the neighborhoods selected for the trial, to ensure accessibility of standardized same-day couples’ VCT services.

  4. Develop and begin implementation of a plan for future sustainability with influence networks.

  1. 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:        

  1. 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’).

  2. 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’).

  3. 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 crossover’).

  1. 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 two hypotheses:

  1. H4: Certain influence network agents will distribute a larger number of couples VCT invitations than others (ranging from minimum 100 to maximum 200/agent).

  2. 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.

  1. 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.

  1. Examine gender roles, relationship intimacy and alcohol use as predictors of these outcomes.

  2. Model HIV specific couple communication as a mediator of the above predictors.

  3. Analyze these effects separately for husbands and wives and examine the concordance in partners’ responses.

  4. Examine differences specific to couples in Zambia and Rwanda.

  1. 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.

  1. 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.

  2. 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.

  3. 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

 








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