Social Science & Medicine 53 (2001) 1397–1411 Voluntary counseling and testing for couples: a high-leverage intervention for HIV/AIDS prevention in sub-Saharan Africa Thomas M. Painter* Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention, Division of HIV/AIDS Prevention- Surveillance and Epidemiology, Prevention Services Research Branch, Mailstop E-46, 1600 Clifton Road, N.E. Atlanta, GA 30333, USA Abstract Most HIV infections in sub-Saharan Africa occur during heterosexual intercourse between persons in couple relationships. Women who are infected by HIV seropositive partners risk infecting their infants in turn. Despite their salience as social contexts for sexual activity and HIV infection, couple relationships have not been given adequate attention by social/behavioral research in sub-Saharan Africa. Increasingly studies point to the value of voluntary HIV counseling and testing (VCT) as a HIV prevention tool. Studies in Africa frequently report that VCT is associated with reduced risk behaviors and lower rates of seroconversion among HIV serodiscordant couples. Many of these studies point out that VCT has considerable potential for HIV prevention among other heterosexual couples, and recommend that VCT for couples be practiced more widely in Africa. However, follow-up in the area of VCT for couples has been extremely limited. Thus, current understandings from social/behavioral research on how couples in sub-Saharan Africa manage HIV risks as well as HIV prevention interventions to support couples’ HIV prevention eﬀorts have remained underdeveloped. It appears that important opportunities are being missed for preventing HIV infection, be it by heterosexual transmission or mother-to-child HIV transmission by mothers who have been infected by their partners. Based on an overview of documentation on VCT in sub-Saharan Africa, this paper proposes that increased attention to couples-focused VCT provides a high-leverage HIV prevention intervention for African countries. The second half of the paper indicates areas where VCT needs to be strengthened, particularly with respect to couples. It also identiﬁes areas where applied social/behavioral research is needed to improve knowledge about how couples in sub-Saharan Africa deal with the risks of HIV infection. Published by Elsevier Science Ltd. Keywords: Africa; Couples; Gender; Heterosexual HIV transmission; HIV- prevention; Voluntary counseling and testing (VCT); Couples’ counseling HIV/AIDS in sub-Saharan Africa through breast-feeding were living in sub-Saharan Africa. The mothers of these infants were infected 23.3 million persons in sub-Saharan Africa were living during heterosexual intercourse (UNAIDS/WHO, 1999). with HIV infection or AIDS by the end of 1999, accounting for nearly 70% of the estimated 33.6 million Couples and heterosexual transmission of HIV infection individuals living with HIV/AIDS worldwide (UN- AIDS/WHO, 1999). The vast majority of these persons Couple relationships of varying stability and longevity were infected during heterosexual intercourse (Allen account for most heterosexual activity between indivi- et al., 1992b; Berkley, 1994). During 1999 nearly 90% of duals in Sub-Saharan Africa (Caldwell, Caldwell, & the 571,000 children born or infected with HIV-1 Quiggin, 1994; Carael et al., 1988; Carael, Cleland, & Ingham, 1994; Carael, Cleland, Deheneﬀe, Ferry, & *Tel.: +1-404-639-6113; fax: +1-404-639-4268/0910/6127. Ingham, 1995; Heise & Elias, 1995; Larson, 1989; E-mail address: email@example.com (T.M. Painter). Morris & Kretzschmar, 1997; Orubuloye, Caldwell, & 0277-9536/01/$ - see front matter Published by Elsevier Science Ltd. PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 4 2 7 - 5 1398 T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 Caldwell, 1992, 1993). In high prevalence areas of extent) printed media to promote HIV/AIDS awareness Africa, cohabiting couples make up a large proportion and behavior change, have been common in sub- of groups at risk from HIV infection. The greatest HIV Saharan Africa since the mid-1980s. Typically these risk for women in these couples is their husband or programs are directed toward an undiﬀerentiated public regular partner (de Zoysa, Sweat, & Denison, 1996; or categories of individuals that are identiﬁed as more Heise & Elias, 1995; King, Allen, Seruﬁlira, Karita, & inclined to engage in higher-risk sexual behaviors. Van de Perre, 1993; McKenna et al., 1997). Messages may, for example, encourage men as members of a gender category to use condoms with non-regular Insuﬃcient social–behavioral knowledge about HIV risk sexual partners, particularly female sex workers. Media and risk management by couples messages are less likely to address details of condom use with the mens’ wives or other regular sexual partners. Despite the salience of couple relationships as Media programs that depict two heterosexual partners contexts where social–behavioral, economic and other together are more often concerned with the technicalities situational factors shape sexual relations and the risks of of safe sex (proper condom use) than with processes of infection from HIV and other sexually transmitted communication and negotiation (or lack thereof) that diseases (STDs), current understandings of HIV risk aﬀect HIV risk and prevention eﬀorts by couples. and risk prevention eﬀorts by persons in couple While media-based programs may occasionally de- relationships in sub-Saharan Africa are unsatisfactory scribe voluntary counseling and testing, they infre- (Baingana, Choi, Barrett, Bayansi, & Hearst, 1995; quently provide speciﬁc messages for couples and are DeZoysa et al., 1996; Ezeh, 1993; Hassoum, 1996; characterized by unidirectional information ﬂow. Mem- McGrath et al., 1993; Seeley et al., 1994). Orubuloye and bers of mass media audiences rarely have opportunities others have characterized as ‘‘extraordinary’’ the lack of to ask questions or obtain clariﬁcation on issues research on the degree to which women (and by pertinent to their particular situations. While media- implication, men) in couple relationships in sub-Saharan based eﬀorts by national AIDS programs in sub- Africa can control and modify their sexual relations with Saharan Africa have contributed to increased levels of partners (Orubuloye et al., 1993; cf. Ezeh, 1993; Van der HIV/AIDS awareness and some improvements in Straten, Kin, Grinstead, Seruﬁlira, & Allen, 1995). knowledge about HIV/AIDS, their impact on behavior Few presentations have been made on couple-focused change outside a few high-risk categories (e.g., female research or prevention interventions at recent annual sex workers) has been much more modest (Cohen & international HIV/AIDS conferences (cf. 12th World Trussel, 1996). Only two countries in Africa } Uganda AIDS Conference, 1998; XIth International Conference and Senegal } are often cited as examples of success on AIDS & STDs in Africa, 1999; XIII International with broader-based behavioral changes leading to a AIDS Conference, 2000). The lack of attention given to decline in HIV seroprevalence levels. Uganda, it must be couples-related issues at international fora is both an noted, has received large amounts of international indicator of and contributing factor to persistent gaps in ﬁnancial and technical support for its HIV/AIDS current understandings about how couples deal with prevention eﬀorts since the early 1990s. HIV risk in developing areas of the world. Given an inadequate knowledge base about social– Facility-based interventions behavioral issues and about the dynamics of couple relationships in particular, it may not be surprising that The small but gradually increasing number of free- HIV prevention interventions for couples sub-Saharan standing VCT centers and the even smaller number of Africa are rare indeed (Baingana, Choi, Barrett, health facilities in sub-Saharan Africa where VCT is Bayansi, & Hearst, 1995; de Zoysa et al., 1995; de oﬀered, represent the other extreme from media-based Zoysa, Sweat, & Denison, 1996; Desclaux & Raynaut, programs for communicating HIV/AIDS prevention 1997; O’Reilly & Piot, 1996). information. Rather than targeting undiﬀerentiated publics with a one-way ﬂow of information, VCT facilities provide health workers with opportunities both Current approaches to HIV prevention in sub-Saharan to provide clients with information, including informa- Africa: how responsive to couples’ needs? tion on their serostatus if they wish, to work with clients on ways of using the information, and elicit questions Media-based interventions and discussion to ensure that clients understand information that is provided. Broad-based HIV/AIDS information programs, be However, VCT facilities in sub-Saharan Africa are they referred to as Information Education and Com- infrequently attuned to couples’ needs and few couples munication (IEC) or Communications for Behavior present together for VCT. Most VCT facilities address Change, and which use the electronic and (to a lesser individual clients who request HIV testing (free-standing T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1399 VCT centers) and who in some cases (e.g., Uganda) The unsatisfactory picture we have of how VCT are willing to pay fees for VCT, or who are invited clients and their partners carry out HIV/STD risk (at urban antenatal clinics or blood banks) to be management may result from a methodological bias of tested for HIV. In the case of antenatal clinics in VCT programs and studies that rely too much on sub-Saharan Africa, women frequent the facilities individual VCT clients, particularly women, as sources primarily for medical consultations, not because of information about both their own and their partners’ they seek HIV testing. Because many pregnant reasoning and actions. women do not know about VCT testing opportunities, The AIDS Information Centre (AIC) in Uganda is where available, before arriving at clinic settings, one exception to the current emphasis on individual they may be surprised by the oﬀer of a HIV test counseling by VCT programs in Africa. While the AIC’s and refuse on the spot or tell counselors that they wish principal focus has been one of providing VCT to to postpone their decisions, often amounting to a individual clients, the Centre’s clientele has changed. deferred refusal (Cartoux et al., 1998; Diaby et al., The number of persons requesting VCT as couples has 1996; Painter et al., 1998). steadily increased from 8% of all clients in 1992 to In these settings VCT clients interact individually with nearly a third currently. Nearly 80% of these couples counseling staﬀ. Clients are invited to rapidly think request HIV testing as a kind of premarital screening about HIV/AIDS and consider having a HIV test, but process, described as ‘‘planning for marriage’’ (Baryar- their discussions are disarticulated from the everyday ama et al., 1996; Turyagyenda, 2000). Several factors realities of communicating, much less negotiating, help explain the increased demand for couples’ VCT, protective actions with their partners who are absent among them a national HIV/AIDS policy in Uganda from the VCT session. that has promoted behavior change and open discussion After the VCT session is over, however, many of AIDS-related issues since the 1980s, resulting in individual VCT clients return to partners in couple greater willingness by couples to be tested together, AIC relationships. Despite their non-involvement in pre-test promotions that target couples with a ‘‘two-for-one’’ decision making, these absent partners can importantly approach, and pressures from young couples’ families aﬀect the decisions that VCT clients make: to accept or and churches to be tested for HIV before marriage. If refuse HIV testing, to return or not for test results and test results show that one partner is infected, the post-test counseling, to disclose test decisions and test relationship often terminates shortly thereafter (Turya- results, and for women who ﬁnd that they are infected gyenda et al., 1998). In response to the increased with HIV, or to enroll where available, in short course demand by couples for VCT, AIC is developing antiretroviral therapies (e.g., zidovudine, nevirapine) to approaches to VCT and post-test follow-up that are prevent mother-to-child transmission of HIV infection more attuned to couples’ situations and needs (Alwano- (MTCT). Edyegu et al., 1998). Partners also aﬀect VCT clients’ ability to follow Outside Uganda, the development of capacity for through on intentions and decisions made during VCT VCT with couples, be they couples-in-the-making or sessions. Eﬀective protective action against HIV/STD established couples, has been slow. Retooling of VCT infection within couple relationships requires commu- approaches will take time and resources but it is needed nication, agreement, and above all, cooperation between to better address couples and a unique and important couple members. The obstacles to carrying out intended opportunity for HIV/AIDS prevention in Africa. VCT protective actions can be particularly daunting for for couples includes two, possibly more social interac- women in couple relationships. The responses that tions between counselors and couple members individu- women encounter to their prevention eﬀorts with male ally and together to discuss HIV risks and feasible partners may vary from silence (indiﬀerent to cool), to approaches to prevention. VCT for couples thus has the resistance and non-cooperation, to threats and physical potential for incorporating sexual partners that are violence. While these factors aﬀect protective actions absent during VCT for individuals, and addressing against HIV infection, they have not been given much obstacles to HIV prevention practice. attention by social/behavioral research and prevention Alternatively, counseling staﬀ may request or encou- interventions in sub-Saharan Africa and other world rage individual clients to ask or encourage partners to be areas (Caldwell et al., 1994; Chaima & Zimba, 1998; tested for HIV. Experience in sub-Saharan Africa Hassoum, 1996; Heise & Elias, 1995; M’Pele, Lallemant- indicates that this approach has been largely unsuccess- LeCoeur, & Lallemant, 1994; Mullick, Abdool Karim, ful, and women encounter particular diﬃculties when & Morar, 1998; Ulin, 1992; cf. Bajos, 1997; Cupach & they try to convince partners to be tested for HIV. Test Metts, 1991; Edgar et al., 1992; Moore & Padian, 1993; rates for male partners of well under 5% have been Moore et al., 1995). Very little is known about the socio- ˆ reported in Cote d’Ivoire (Ba et al., 1995), Democratic sexual lives of couples in sub-Saharan Africa after one Republic of Congo (Heyward et al., 1993), Mali (Le or both members has been tested for HIV. Palec, 1994), Rwanda (Ladner et al., 1996), and 1400 T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 Zimbabwe (Dube, Machekano, McFerland, & Mandel, et al., 1992a, b; Keogh, Allen, Almedal, & Temahagili, 2000). 1994; King et al., 1993; Ladner et al., 1996; van der Straten et al., 1995); Uganda (AIDS Information Centre, 1994; Lainjo, Wawer, Lutalo, Sewankambo, & Evidence from studies and prevention interventions Kelly, 1994; Moore et al., 1993; M’Pele et al., 1994; Muller et al., 1992; Serwadda et al., 1995); and Zambia VCT studies and interventions from 1990 to 1997 (Feldblum, Hira, Godwin, Kamanga, & Mukelabai, 1992; McKenna et al., 1997). Similar to ﬁndings often VCT has received considerable scrutiny in the reported elsewhere, many of these studies reported scientiﬁc literature during the 1990s. Reviews (e.g., signiﬁcant reductions of risk behavior, and when Beardsell, 1994; Beardsell & Coyle, 1996; Campbell biomedical outcomes are recorded, lower rates of et al., 1997; Choi & Coates, 1994; Gerber, Campbell, seroconversion in HIV serodiscordant couples following Dillon, & Holtgrave, 1994; Higgins et al., 1991; Irwin, VCT. They frequently recommended as well that VCT Valdiserri, & Holmberg, 1996; Oakley, Fullerton, & for couples should be practiced more widely in sub- Holland, 1995; Wolitski, MacGowan, Higgins, & Saharan Africa. A more detailed review of the scientiﬁc Jorgensen, 1997) and studies in African and non-African literature on VCT during this period is beyond the scope settings have assessed the eﬀectiveness of VCT in of this paper. Readers are referred to the sources cited reducing risk behaviors and occasionally rates of HIV immediately above for additional details. seroconversion among VCT recipients (e.g., Allen et al., 1992a, b; De Vincenzi, 1994; Feldbulm, 1991; Kamenga et al., 1991; Moore et al., 1991; Moore et al., 1993; Muller et al., 1992; Padian, O’Brien, Chang, Glass, & Francis, 1993; Pickering, Quigley, Pepin, Todd, & More recent VCT studies Wilkins 1993; Temmerman et al., 1990; van der Straten et al., 1995). The most convincing evidence yet about the eﬀective- Studies report mixed results in terms of reduced risk ness of VCT was reported in the late 1990s from studies behaviors and HIV infection rates and VCT seems to in Africa and the United States. Randomized controlled have little eﬀect on pregnancy decisions by HIV-infected trial studies of counseling and testing in Kenya, women (and importantly, their partners), but substantial Tanzania, Trinidad (Coates et al., 1998; Gregorich, risk-reduction and lower rates of seroconversion were Kamenga, Sangiwa, Furlonge, & Balmer, 1998; Sangi- often reported for HIV serodiscordant couples, particu- wa, Balmer, Furlonge, Grinstead, & Kamenga, 1998, larly in couples where both partners know their The Voluntary HIV-1 Counseling and Testing Eﬃcacy serostatus. Behavior changes among discordant couples Group, 2000) and the US (Kamb et al., 1998) reported were not uniform, however, pointing to gender-asso- lower incidence of STDs and longer periods of HIV/ ciated power diﬀerences within couple relationships. STD risk reduction among persons receiving VCT than Condom use in discordant couples in sub-Saharan among persons who received HIV/AIDS prevention Africa after VCT, for example, was more frequent and information using health education formats. consistent in couples where men were HIV seronegative Study results in the early 1990s indicated that VCT (Kamenga et al., 1991; Maposhere et al., 1996; provided net economic beneﬁts in developed country Serwadda, Gray, Sewankambo, & Wawer, 1994; Ser- settings (e.g., Holtgrave, Valdiserri, Gerber, & Hinman, wadda et al., 1995; van der Straten et al., 1995). 1993), but cost-eﬀectiveness analysis was not applied to Debates over VCT during much of the 1990s developing country settings until recently. The multi-site concerned the appropriateness of VCT for developing study in Kenya and Tanzania also assessed the cost- country settings as well as its eﬀectiveness. International eﬀectiveness of VCT. Once again, the results were organizations and African health ministries were reticent supportive of VCT as a prevention intervention in because of doubts about the cost-eﬀectiveness of VCT in resource-constrained settings. Data published in 2000 countries where access to basic health services is limited. show that 1104 HIV-1 infections were averted in Kenya Per-capita health expenditures in sub-Saharan Africa are at a cost of $249 per averted infection and that 895 among the lowest in the world. infections were averted in Tanzania at a cost of $346 per Nevertheless, evidence concerning the beneﬁts of VCT averted infection. The infection costs of $12.77 and continued to accumulate during the 1990s from studies $17.70 per disability-adjusted life-year saved in Kenya in several African countries, among them, the Demo- and Tanzania respectively, compare favorably with costs cratic Republic of Congo (Heyward et al., 1993; Jingu of other interventions (Sweat et al. 2000; cf. Van de et al., 1990; Jingu, Mbuyi, Ndilu, Assina, & Musingayi, Perre, 2000). VCT was found to be most cost eﬀective 1993; Kamenga et al., 1991); Congo (M’Pele, Lallemant- for HIV-1 seropositive persons and for persons who Lecoeur, Lallemant, & Samba, 1991); Rwanda (Allen received VCT as couples. T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1401 A favorable moment for couples’ VCT as a component of HIV infection will require better protection of women HIV/AIDS prevention strategies in sub-Saharan Africa? from heterosexual HIV infection. Eﬀective prevention requires cooperation from women’s partners. This gives Accumulating evidence that VCT works and is cost- added urgency to the need for health facility-based VCT eﬀective programs in sub-Saharan Africa that incorporate women’s sexual partners through targeted recruiting Studies in sub-Saharan Africa during the 1990s eﬀorts and community outreach to couples (Diaby et al., produced evidence indicating, albeit somewhat incon- 2000; Painter et al., 1999, 2000). sistently, that VCT can be eﬀective as a HIV-prevention tool, particularly when members of couples participated together in the VCT process. Evidence of VCT-induced HIV risk reductions and rates of HIV seroconversion A favorable moment for VCT in sub-Saharan Africa? was particularly strong in the case of HIV serodiscor- dant couples. Regardless of study results, however, The accumulation of evidence about the eﬃcacy, cost- investigators were nearly unanimous in noting that VCT eﬀectiveness and the acceptability of VCT in sub- for couples may be a particularly powerful HIV Saharan Africa, and the increased awareness of the prevention tool. Researchers very often recommended prevention potential of VCT for couples suggest that further studies of couples-focused VCT and called for HIV/AIDS prevention has reached a critical } socio- the increased use of VCT for couples in sub-Saharan logical } juncture. In eﬀect, by providing high-quality Africa. More recent results from randomized clinical VCT and associated support for couples, HIV/AIDS trial studies in Kenya and Tanzania have provided prevention is returning full-circle to the most typical and additional evidence that VCT is an eﬀective and widespread socio-cultural setting for heterosexual HIV appropriate prevention intervention in the resource- infections in sub-Saharan Africa: couple relationships. constrained situations typical of countries in sub- Rather than simply addressing undiﬀerentiated publics, Saharan Africa. or individual VCT clients in the absence of their sexual partners, the stage is set for VCT work with couple Greater international support for VCT members together and in relation to the roles and responsibilities and the opportunities and constraints The political climate also became more supportive of that make up everyday life for couples, and which aﬀect VCT in developing country settings during the late HIV risk and risk prevention. 1990s. UNAIDS and other international organizations Assuming for the moment that this is indeed a engaged in HIV/AIDS prevention (e.g., the United propitious moment for HIV/AIDS prevention in sub- States Agency for International Development [USAID], Saharan Africa, what should be done to capitalize on the the World Bank) have expressed strong support for opportunities it presents? The next section of the paper making VCT available to populations in developing will address these issues by indicating several areas countries (UNAIDS, 1998; The World Bank, 1999). where VCT needs to be strengthened for work with Intervention research not directly focused on VCT couples, and by identifying areas where applied social/ eﬃcacy, but which included VCT as a component, has behavioral research is needed to improve knowledge also contributed to a change from widespread scepticism about how couples in sub-Saharan Africa deal with the to increasing support among international agencies for risks of HIV infection. The following remarks are based VCT as a prevention tool in Africa. In 1998 the results on experiences described in sources cited earlier and on of randomized clinical trials in Thailand and Cote ˆ the author’s experiences with applied research related to d’Ivoire demonstrated that MTCT of HIV-1 can be implementation of VCT programs at free-standing VCT reduced by 50% among non-breast-feeding Thai women facilities and in mother–child clinic settings in Uganda and by nearly one-third among breast-feeding women in ˆ and Cote d’Ivoire, respectively (Campbell et al., 2000; Cote d’Ivoire (Shaﬀer et al., 1999; Wiktor et al., 1999). ˆ Diaby et al., 2000; Painter, 1996; Painter et al., 1998, Very shortly thereafter, UNAIDS and UNICEF in- 1999, 2000). Clearly, many of the recommendations itiated several pilot prevention interventions in sub- about areas where VCT needs to be strengthened for Saharan Africa with a view toward upscaling of MTCT couples also apply to VCT in general. Likewise, the prevention after reality checks in typical health care areas that have been identiﬁed as urgently needing more settings. social/behavioral research overlap to a degree with needs Preventing mother-to-child HIV transmission requires for innovative and improved approaches to providing HIV testing and counseling of pregnant women. Because VCT in Africa. In practice, a much stronger linkage is antenatal clinic settings cover only individual pregnant needed between the generation of knowledge by applied women who seek consultations for healthy babies, and operational social/behavioral research and VCT meeting the challenge of protecting African infants from interventions for couples. 1402 T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 What is to be done? – Their own risk backgrounds and actions. – Prevention options and obstacles they face Intervention processes with risk reduction eﬀorts during sexual relations. Strengthen VCT procedures, staﬀ capacity & – Fears associated with HIV and the diﬃ- performance culties associated with public knowledge of Target couples in VCT recruitment eﬀorts. The one’s participation in HIV prevention prevention potential of VCT for couples in Africa actions. can be realized only if more couples learn about and – Disclosure of HIV test decisions and gain access to VCT. Components of a more results, of intentions or the wish to engage specialized VCT package for couples would include: in prevention actions such as using con- doms, VCT, or in the case of HIV * Frequent, clear and accurate media-based informa- seropositive women, antiretroviral therapy tion programs using multiple languages are needed to to reduce MTCT. increase access to information on VCT, with – The importance of eﬀorts to reduce and particular attention to the importance of VCT for avoid conﬂict and violence related to couples for preventing both heterosexual and prevention eﬀorts or to the disclosure to mother–child HIV transmission. partners of information about serostatus. * Community outreach to couples in areas surrounding – Approaches to developing realistic and VCT facilities. This interactive approach is needed as acceptable HIV prevention strategies with- a follow-on and complement to media-based infor- in couples, detailing roles and responsibil- mation programs. Speciﬁc approaches need to be ities of couple members, thereby better developed through pilot eﬀorts and operational equipping } and empowering } couples research. They would aim to optimize opportunities to work together rather than at cross- for contacts by trained outreach workers and purposes for HIV prevention. counseling staﬀ (both of whom could possibly be – A focus on the importance of cooperation recruited from among HIV seropositive men and by couple members for successful eﬀorts to women and couples that have coped successfully protect themselves (and their outside sex- after VCT and receiving HIV seropositive test ual partners if these external relationships results) with couple members together and individu- appear to be non-negotiable) and their ally to ensure that discussion and queries occur and children from HIV infection. that speciﬁc question are answered. Recent and * Counseling for couple members both individually current couples-focused initiatives in Zambia and together, during pre- and post-test periods. (McKenna et al., 1997) and Uganda (Alwano- * Multiple and variable post-test follow-up of couples Edyegu et al., 1998) respectively, to recruit and better during the time after post-test counseling to better address couples’ needs, provide useful lessons for understand couple coping, identify diﬃculties and couple recruitment eﬀorts elsewhere in sub-Saharan successes, provide couples with support or referrals, Africa. and further strengthen the capacity of VCT facilities * More specialized topics must be covered during for work with couples. group information sessions when used, when couples * Community-based support for couples, including con- arrive at VCT facilities, during pre- and post-test ﬁdential support groups for couple members, together counseling sessions and during facility- or commu- and separately, organized according to gender, seros- nity-based follow-up contacts with couples after tatus, status of the couple relationship, etc. VCT. Coverage would require that counseling staﬀ * Stronger post-test support for coping and HIV risk address a range of possible topics as appropriate management is particularly important for HIV during the VCT process. This should not be done in a seropositive women in couples, given their social lock-step progression, but be based on the opportu- vulnerability, particularly to being ejected by part- nities and needs that occur during encounters with ners from couple relationships, and their frequently couple members together and separately. Coverage reduced access to sources of material and moral would combine the provision of information with support. For purposes of identifying opportunities exchange and discussion. More specialized informa- for providing support to HIV+ women, VCT tion would include: facilities need to work with women in a continuum * The importance and contribution to HIV risk of couple conﬁgurations: reduction of greater openness and communica- * Ongoing couple relationships where male part- tion between couple members about: ners are supportive or unsupportive following – HIV risk and prevention knowledge. disclosure of the woman’s HIV+ serostatus. T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1403 * Ongoing couples where women do not or terms of the opportunities they oﬀer HIV prevention cannot disclose their serostatus to partners. eﬀorts as well as the obstacles they may represent. * Couple relationships that have been seriously While the potential for increasing access to VCT by disrupted or destroyed due to prior conﬂicts embedding it within a range of health services is related to sexual issues or following disclosure particularly important for hospitals and mother–child of the woman’s HIV+ serostatus. clinics, free-standing VCT centers in high prevalence * Periodic assessments and strengthening of key areas also stand to gain from increased client response, components at VCT facilities, including: hence increased acceptability and eﬀectiveness of VCT, * Counseling staﬀ skills and demeanor to ensure by broadening the scope of diagnostic, counseling, that couples (and all other clients) are well- treatment, care and referral options they oﬀer. Here, received by VCT staﬀ and feel that counseling once again, more comprehensive service programs that staﬀ are genuinely interested and supportive of incorporate VCT need to target households and couples their situations as couples, and also have the by a combination of outreach and delivery of services expertise to deal with issues of couple commu- that are suﬃciently eﬀective and discrete that both nications and risk reduction in couple settings. members of couples will be encouraged to beneﬁt. * The conﬁguration of space to ensure that Integrating VCT with other health services can serve conﬁdentiality is assured for comfortable, eﬀec- multiple objectives, including the reduction of social tive work with all clients, including couple stigma, but signiﬁcant progress with destigmatizing members together and separately. HIV/AIDS will require more robust eﬀorts at the highest levels of African government. This will be Associate VCT with a broader range of health services. possible only if African heads of state spearhead and Increased international interest in and support for VCT sustain eﬀorts to create opportunities in civil society in sub-Saharan Africa is salutary, however successfully where individuals and couples perceive social and moral addressing the severe social stigma associated with HIV/ support for their eﬀorts to ‘‘do the right thing’’: protect AIDS and increasing the acceptability of VCT as a HIV themselves, their sexual partners, and their infants from prevention tool will require that VCT increasingly be HIV infection. made available as part of a broader range of health services that focus on mother–child, reproductive, and Better assessment of VCT processes and outcomes family health issues (Cartoux et al., 1998; Dabis, Newell, Assess outcomes. Social–psychological, behavioral Fransen, Saba, & De Vincenzi, 1998). and biomedical outcomes of VCT programs need to be Concern for a broader range of mother–child health assessed more consistently and rigorously. Program issues, particularly protecting infants whose survival is evaluations are critical to judging impact and success, critical for socio-cultural continuity between generations but are often accorded lower priority operationally may give heterosexual HIV prevention a salience and because of the primacy that VCT facilities give to acceptability greater than current levels that result from serving clients. It’s noteworthy that much of the debate prevention messages targeted largely to undiﬀerentiated over VCT eﬀectiveness during the 1990s was fueled by a publics or individual VCT clients. Currently, one of the lack of solid evaluation data and little consensus on the trade-oﬀs that contribute a great deal to consistently low evaluative criteria used during program assessments. rates of condom use in sub-Saharan African involves Improved program assessments will require more (particularly, but not only for men) foregoing some detailed follow-up of VCT clients as they and their sexual pleasure to prevent HIV infection. If the tradeoﬀ partners cope with knowledge of serostatus, HIV risk } or the stakes } were more widely redeﬁned in Africa and risk reduction during the time that follows HIV as one of protecting children } the next generation } testing. Given the realities of post-HIV test coping and from HIV/AIDS, condoms and diminished sexual HIV risk management, and the need to tailor counseling pleasure may become more acceptable. and support services to couples’ needs, follow-up needs To date there is very little evidence that HIV to focus more on speciﬁc couple proﬁles. For example, prevention programs in sub-Saharan Africa are linking relationship longevity and stability, marital status, heterosexual and mother-to-child HIV transmission in serostatus (HIV+ discordant, HIV+ concordant or this way as they promote HIV prevention and VCT. high and low risk HIVÀ negative), members’ HIV Success with this approach will require that more infection risk proﬁles, and sources and quality of post- prevention work be done with couples and with the test support from family, friends, etc., are among the larger families and kinship relationships of which they factors that require attention when looking at post-test are members. The stakes of HIV/AIDS prevention in coping and HIV risk management by couples. sub-Saharan Africa involve more than preferences by These attributes of couples and their members aﬀect individuals and couples. These factors need to be the opportunities and constraints that couples in sub- brought into the prevention picture and examined in Saharan Africa face when they deal with HIV risk and 1404 T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 risk reduction. Very little is known about the eﬀects of these issues at the international conference 2 years these factors on HIV risk management by couples. ˆ earlier in Abidjan, Cote d’Ivoire. Eﬀective VCT for couples requires that these factors be African heads of state, prime ministers, ministers of better understood and addressed by VCT programs for health, and other key lay and religious leaders at couples. multiple levels must play a more supportive role in The use of qualitative data analysis and ethnographic creating national and local environments that empower methods can be particularly helpful for eﬀorts to better HIV prevention eﬀorts by persons in couple relation- understand diﬀerent levels of success by couples with ships. Just as media-, community-, and facility-based coping and HIV risk management over time (Painter programs need to tailor their messages and support et al., 2000). services for couples, so African political and public Develop realistic criteria for assessing VCT interven- health leaders need to speak more often and more tions. Broadly accessible evaluative criteria for guiding convincingly about the importance of HIV prevention, and assessing VCT quality assurance need to be including VCT, for couples. Consider the potential developed and disseminated, both nationally and within impact of a mini-series on TV and radio that follows an and across the Anglophone, Francophone and Luso- African head of state and his wife through the steps of phone cultures of public health organization and VCT for couples: considering the experience, encounter- procedures that shape service delivery, including VCT ing and coping with it, and extolling its value for the and other prevention interventions in sub-Saharan many couples that are tuned in. It can be predicted that African countries. Evaluative criteria need to be broadly the news of a program like this would spread rapidly, comparable across typical VCT settings, but also need to even among persons without easy access the media, take into account localized resource constraints, prac- drawing more persons to the program and to facilities tices and features of the settings where health services where VCT is oﬀered. are delivered. VCT guidelines issued by UNAIDS and Information on VCT must be widely accessible to other international organizations are useful as points of couples. Thanks to widespread information programs, reference, but there is a continuing need for reality HIV/AIDS awareness has increased considerably in sub- checks against local conditions and possibilities. The Saharan African countries since the mid-1980s. Despite veriﬁcation and needed modiﬁcations in program these eﬀorts, presentations at international conferences approaches must be based on the results of intervention continue to report widespread and persistent erroneous assessments and applied/operational social/behavioral beliefs among persons surveyed about how HIV is research. There is no single answer to the question, transmitted and prevented. ‘‘What constitutes best practice for VCT service delivery National HIV/AIDS information programs and their in sub-Saharan Africa?’’ international partners must provide their publics with accurate, up-to-date information. But how many na- Intervention environments tional HIV/AIDS program in sub-Saharan Africa have incorporated prevention information based on recent Government policies must be supportive of HIV/AIDS developments including syndromic management of prevention sexually transmitted infections (STIs), VCT, including Commitment at the highest levels of government is the added value of VCT for couples, more rapid and less (still) needed for successful HIV/AIDS prevention in sub- invasive HIV testing technologies, and prevention of Saharan Africa. Reports of HIV prevention success from mother-to-child HIV transmission? Most likely, not countries in Africa such as Senegal and Uganda where many. Information on and access to these and other governments have joined forces with broader constitu- public health developments must be made widely encies including non-governmental organizations accessible if Africans are to genuinely beneﬁt from new [NGOs] and religious leaders (UNAIDS/WHO, 1998) screening, prevention and treatment options that be- are encouraging. Heads of state and other important come available. leaders in both countries have provided high-level, high- The lack of synchronization between new treatment proﬁle support of HIV prevention eﬀorts. options and public access to prevention information can However, session after session at the XIth Interna- create obstacles to prevention. Among the HIV-1 tional Conference on AIDS and STDs in Lusaka, seropositive pregnant women who do not return for Zambia in 1999 made it abundantly clear that Uganda follow-up visits leading to free zidovudine therapy at 36 and Senegal are } and may long remain } exceptional weeks of gestation at mother–child clinics in Abidjan, cases in sub-Saharan Africa (cf. Caldwell, 1999). The ˆ Cote d’Ivoire, some say they refuse because they Lusaka conference was characterized by a palpable have only heard that there is no treatment for AIDS. sense of disappointment and frustration among partici- They do not believe clinic staﬀ who now tell them that pants over the lack of commitment by African leaders to medications can protect their infants from HIV infec- combating HIV/AIDS despite considerable hoopla over tion. This suggests that improvements are needed in T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1405 community-based dissemination of HIV prevention and the number of clients can easily be twice the number information prior to pre-natal consultations. In addition that ordinarily request VCT. to providing accurate and up-to-date information on Community outreach interventions can be helpful, but prevention options, more eﬀort is needed to integrate like most HIV prevention actions, they are introduced the women’s partners in the mother-to-child de novo. Rarely do these arise spontaneously from prevention eﬀort. Partners need to be aware of preven- African communities aﬀected by HIV/AIDS (but cf. tion options and need to support women’s eﬀorts to Waliggo, 2000). It can be anticipated that the accept- beneﬁt from available options. This will require VCT ability, eﬀectiveness and sustainability of outreach and approaches that are more receptive to work with both the behavioral and normative changes it aims to couple members rather than approaching only indivi- promote will be enhanced to the degree that HIV dual pregnant women as is currently the case in prevention outreach actions are linked to existing, antenatal settings in sub-Saharan Africa (Diaby et al., community-based structures for social support. Identi- 2000). fying these support networks and developing linkages is Community outreach is needed. The social stigma, an area that requires more attention by both prevention shame, and silence that are widely associated with HIV/ interventions and social/behavioral research in sub- AIDS, together with the semi-public nature of many Saharan Africa. social interactions in African communities, can create major obstacles to eﬀorts by individuals and couples Areas where research is needed to seek HIV prevention information and engage in protective actions (Caldwell, 1999). Experience of Experiences in sub-Saharan Africa reveal that VCT VCT services in African countries as diverse as and VCT for couples in particular have a great deal to Cote d’Ivoire (Coulibaly, Mselatti, & Dedy, 1996; ˆ oﬀer current prevention eﬀorts but numerous questions Diaby et al., 1996) and Zambia (McKenna et al., remain. The questions are both social/behavioral and 1997), and in settings as diﬀerent as pre-natal clinics operational in nature, and must be addressed as VCT is and free-standing VCT centers, all indicate that scaled up in Africa. There is a need for improved basic uptake of VCT services can be low despite high knowledge that has implications for the development of seroprevalence levels in the general population. The prevention interventions; for example, concerning how underutilization of HIV prevention services despite couples negotiate HIV risk reduction and cope during high levels of HIV infection risk indicates that the post-test period. Likewise a clearer picture is needed greater eﬀorts are needed to broaden eﬀective access about how interventions can enhance prevention eﬀec- to VCT in sub-Saharan Africa. As noted above, it tiveness; interventions such as community outreach, is not enough that broad-based mass media provide increased recruitment of couples to VCT, specialized HIV prevention information. Too often this information counseling modules for couples, and the development of is short on details and precludes any interaction support structures for couples during the post-test between providers and recipients of information. Nor, period. on the other hand, is it enough for counseling staﬀ simply to await the arrival of clients. Improved Sexual relations and HIV risk-reduction by couples access to VCT in sub-Saharan Africa will require that Our understanding of sexual relations and risk VCT programs, whatever their organizational setting, reduction with sexual partners in sub-Saharan Africa reach out to the communities they serve. has not improved much since 1993 when Orubuloye Zambia and Uganda once again provide examples of and others described the lack of research on these VCT programs where these complementary information issues as ‘‘extraordinary’’ (Orubuloye et al., 1993). and recruitment eﬀorts have been used to target couples. More research is needed on risk behaviors and In Lusaka, Zambia, a free-standing VCT program risk prevention by men and women in couple relation- undertook community outreach in an eﬀort to increase ships. Factors associated with successes and failures of couples’ participation in VCT (McKenna et al., 1997). couples with HIV prevention need to be studied and Individuals were selected from the community, trained clariﬁed. for household outreach, and assigned to contact couples Data on risk factors are commonly collected but very in their home communities. Uptake of VCT by couples little is known about communications within couples. increased after this outreach intervention. The AIDS There is a need for both cross-sectional and longitudinal Information Centre in Uganda periodically advertises social/behavioral studies of successful and unsuccessful special oﬀers to couples through spot announcements on couple communications in relation to coping and HIV the radio. On Valentine’s Day, for example, couples can prevention outcomes. Learning from the experiences of receive VCT for the price of one person (the equivalent couples over time will be essential for more eﬀective of about $3.50 US) (Elizabeth Marum, Personal VCT and support interventions for couples in sub- communication). In general the response is very strong Saharan Africa. 1406 T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 Gender, power and eﬃcacy of HIV risk management by or as separate and complementary interventions such as couples support groups (Waliggo, 2000). Despite the importance of gender-related power It is particularly important that social/behavioral diﬀerences within couple relationships for HIV risk research identify strategies that couples develop them- and risk reduction (Becker, 1996; Heise & Elias, 1995; selves for dealing with HIV risk and the knowledge of Pivnick, 1993; Ulin, 1992; Worth, 1989), gender issues personal serostatus as well as the features that diﬀerent have not been given much attention by social science couples share in common. Information of this kind research and HIV prevention programs in sub-Saharan would be most useful for ensuring that external Africa (Caldwell et al., 1994; Chaima & Zimba, 1998; prevention and support interventions reinforce strategies Ezeh, 1993; Hassoum, 1996; M’Pele et al., 1994; Mullick which, because developed by couples themselves, are et al., 1998; Obbo, 1993, 1995; Rwabukwali et al., 1994; more acceptable to them. cf. Kashima, Gallois, & McCamish, 1992, 1993). Gender aﬀects communications about and negotiation of HIV Assessment of strategies for disseminating VCT risk reduction in many important ways. Additional data information to and recruitment of couples to VCT are needed on these points and need to inform VCT Operational research is needed to assess eﬀective interventions for couples. methods for disseminating HIV prevention information Sexual violence in couples is one particularly im- targeted to couples. Possible approaches would include portant gender issue. Sexual violence is a multifaceted the coordinated and complementary use of both threat to the well-being of women and their children and targeted media-based communications and more inter- a cause of fractured couple and family relationships in active communications with couple members using sub-Saharan Africa. Social/behavioral research and community outreach. Despite reports during 1997 of HIV/AIDS prevention interventions must give greater promising outreach eﬀorts for couples in Zambia, VCT attention to sexual violence in relation to HIV preven- programs in sub-Saharan Africa rarely include outreach tion and coping by couples in sub-Saharan Africa eﬀorts to households and couples in surrounding (Assaa Nguefack, Koua, & Kouakou, Nhaway, 2000; communities. This potentially very important compo- Maman, Mbwambo, Hogan, Kilonzo, & Weiss, 2000; nent of successful VCT for couples needs much more Nzegwu, 2000). attention. Existing sources of support and constraints for HIV risk VCT organization and processes: How does it work? reduction by couples The sociology of VCT } of the organizational Likewise, attention needs to be given to the broader structure and processes of VCT } has been seriously social contexts within which couple members are or are neglected in sub-Saharan Africa. The social organization not able to protect themselves from HIV infection. and the professional cultures of VCT, including staﬀ/ Examples include the presence or absence of support staﬀ and staﬀ/client interactions must be better under- from family, friends and other signiﬁcant persons. These stood before improvements can be eﬀected in VCT support networks are an example of a diversity of socio- practice. cultural and economic structures of opportunity and constraint that aﬀect the ability of couples to beneﬁt Outcome successes and problems from HIV prevention interventions in sub-Saharan Are successful (and unsuccessful) coping and HIV risk Africa and very little is known about them (Amaro, reduction outcomes of VCT for couples attributable to 1995; Bajos, 1997; Beardsell, 1994; Des Jarlais, Padian, particular staﬀ actions, program policies, or are post-test & Winkelstein, 1994; Farmer, Connors, & Simmons, successes and failures chance occurrences? Operational 1996; Heise & Elias, 1995; Lurie, Hintzen, & Lowe, research on recurrent success and problem cases is 1995; O’Reilly & Piot, 1996; Sweat & Denison, 1995; needed to complement program evaluations and to Worth, 1989). identify personal and organizational features associated with successful and unsuccessful social/behavioral and Additional sources of support for coping and HIV-risk biomedical outcomes among couples. reduction by couples after HIV testing Operational research is needed to clarify the social- Social impacts of VCT cultural feasibility of providing additional support to While VCT programs target individuals and occa- couples for HIV prevention eﬀorts. Follow-up studies sionally couples, their actions may gradually contribute are needed of couples with diﬀerent serostatus and risk to a critical mass in surrounding communities because of proﬁles to characterize and better understand how they the presence of persons who have accepted or refused cope. Information from successful and unsuccessful HIV testing and have gained some familiarity with VCT. cases will be useful for developing supportive interven- This critical mass of persons and of shared experience tions, either as part of extended follow-up for couples, and knowledge, may result in broader social impacts, T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1407 including changes in community values and norms that not necessarily reﬂect those of the Centers for Disease aﬀect persons beyond those who have participated Control and Prevention. directly in VCT. Examples of change include greater communication and openness in everyday life about HIV prevention and the advisability of risk-reduction, References decreased denial about the existence of AIDS, enhanced understanding and acceptability of available prevention AIDS Information Centre. (1994). Impact of social support club options, including VCT, greater acceptance of and following HIV counseling and testing in Kampala, Uganda. support for persons who have been tested for HIV and AIDS Information Centre, Kampala. greater support for disclosure of HIV test decisions and Allen, S., Seruﬁlira, A., Bogaerts, J., Van de Perre, P., Nsengumuremyi, F., Lindan, C., Carael, M., Wolf, W., test results. The broader social impacts of couples- Coates, T., & Hulley, S. (1992a). Conﬁdential HIV testing focused VCT are of particular signiﬁcance given that, and condom promotion in Africa: Impact on HIV and ﬁrst, the salience of couple relationships to heterosexual gonorrhea rates. Journal of the American Medical Associa- transmission of HIV infection in sub-Saharan Africa tion, 268(23), 3338–3343. and second, the obstacles that couples often face with Allen, S., Tice, J., Van de Perre, P., Seruﬁlira, A., Hudes, E., communicating about sexuality and about HIV risk Nsengumuremyi, F., Bogaerts, J., Lindan, C., & Hulley, S. reduction. To date the broader social impacts of VCT (1992b). Eﬀect of serotesting with counseling on condom beyond the outcomes recorded for individual or couple use and seroconversion among HIV discordant couples in VCT clients have been ignored in sub-Saharan Africa. Africa. British Medical Journal, 304, 1605–1609. Alwano-Edyegu, M. G., Downing, R., Marum, E., Baryarama, F., Campbell, C., Dondero, T., Hu, D., Kalule, J., Otten, R., Rayﬁeld, M., Smith, D., & Wangalwa, S. (1998). Conclusion Protocol: Evaluation study of risk-reduction interventions for HIV discordant and high-risk concordant negative This paper has provided a brief overview of results couples. AIDS Information Centre and Uganda Virus from recent research and HIV prevention interventions Research Institute, Kampala, Uganda and Centers for in sub-Saharan that focus on couples and HIV risks, Disease Control and Prevention, Atlanta, Georgia USA, VCT, and in particular, VCT for couples. It has been 18 January. proposed that the growing body of research and Amaro, H. (1995). Love, sex, and power: Considering women’s program evidence from sub-Saharan Africa which is realities in HIV prevention. American Psychologist, 50(6), supportive of VCT for couples as a HIV prevention tool, 437–447. Assaa Nguefack, S. R., Koua, L., Kouakou, O., & Nhaway, P. together with an increasingly supportive international (2000). Sexual violence control as a means of preventing policy environment for VCT, have created a unique AIDS in Ivory Coast. XIII international AIDS Conference, sociological conjuncture for HIV prevention in Africa. Durban, 9–14 July [abstract WeOrD565]. In eﬀect, developments in research, interventions and Ba, A., Ekpini, E., Wiktor, S. Z., Sibailly, T., Diaby, L., policy have brought us back to basics of HIV prevention Maurice, C., Whitaker, J. P., & Greenberg, A. E. (1995). that have been neglected for too long by social/ Establishment of an HIV counseling and testing program behavioral research and prevention interventions in among pregnant women attending an antenatal clinic in Africa: couple relationships. This conjuncture reveals a ˆ Abidjan, Cote d’Ivoire. IX international conference on AIDS need for change in prevention paradigms to ensure a & STD in Africa. Kampala, 10–14 December [abstract better sociological ﬁt between how persons in Africa WeD833]. Baingana, G., Choi, K. H., Barrett, D. C., Bayansi, R., & confront and deal with HIV risks on the one hand, and Hearst, N. (1995). Female partners of AIDS patients in on the other, how prevention interventions that aim to Uganda: Reported knowledge, perceptions and plans. support prevention actually focus their attention and AIDS, 9(Suppl. 1), S15–S19. resources. More work with couples promises to enhance Bajos, N. (1997). Social factors and the process of risk the already promising potential of VCT for HIV/AIDS construction in HIV sexual transmission. AIDS Care, 9(2), prevention sub-Saharan Africa. 227–237. Baryarama, F., Kalule, J., Gumisiriza, E., Alwano-Edyegu, M. G., Marum, E., & Moore, M. (1996). Couple counseling and Acknowledgements HIV testing in Uganda: Four years of experience at the AIDS Information Centre. 11th World AIDS conference, Vancouver, 7–12 July [abstract Tu.C.451]. The author wishes to thank Carl Campbell, Tim Beardsell, S. (1994). Should wider HIV testing be encouraged Dondero, Lynda Doll and several anonymous reviewers on the grounds of HIV prevention? AIDS Care, 6(1), 5–19. for their helpful comments on earlier drafts of this Beardsell, S., & Coyle, A. (1996). A review of research on the paper, however the author accepts sole responsibility for nature and quality of HIV testing services: A proposal for the form and content of the current version. The views process-based studies. Social Science & Medicine, 42(5), expressed herein are those of the author alone and do 733–743. 1408 T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 Becker, S. (1996). Couples and reproductive health: A review Cohen, B., & Trussel, J. (Eds.) (1996). Preventing and mitigating of couples studies. Studies in Family Planning, 27(6), AIDS in sub-Saharan Africa. Research and data priorities for 291–306. the social and behavioral sciences. Washington, DC: Berkley, S. (1994). Public health measures to prevent HIV National Academy Press. spread in Africa. In M. Essex, S. Mboup, P. J. Kanki, & M. Coulibaly, D., Mselatti, P., & Dedy, S. (1996). Aspects R. Kalengayi (Eds.), AIDS in Africa (pp. 473–495). New psychosociaux du despistage VIH/Sida chez les femmes York: Raven Press. enceintes a Abidjan en 1995. Colloque International sur les Caldwell, J. (1999). Reasons for limited sexual behavioral Sciences Sociales et SIDA en Afrique: Bilan et Perspectives, change in the sub-Saharan AIDS epidemic, and possible Sali Portudal, Senegal, 4–8 Novembre, vol. 2. (pp. 407–414). future intervention strategies. In J. C. Caldwell, O. Dakar, Senegal: CODESRIA-CNLS. Caldwell, J. Anarﬁ, K. Awusafo-Asare, J. Ntozi, I. O. Cupach, W. R., & Metts, S. (1991). Sexuality and Orubuloye, J. Marck, W. Cosford, R. Colombo, & E. communication in close relationships. In K. McKinney, Hollings (Eds.), Resistance to behavioural change to reduce & S. Sprecher (Eds.), Sexuality in close relationships HIV/AIDS infection in predominantly heterosexual epidemics (pp. 93–110). Hillsdale, NJ: Lawrence Erlbaum Associates, in third world countries (pp. 241–256). Canberra: Health Inc.. Transition Centre, Australian National University. Dabis, F., Newell, D. L., Fransen, L., Saba, J., & De Vincenzi, Caldwell, J. C., Caldwell, P., & Quiggin, P. (1994). The social I. (1998). Prevention of mother-to-child transmission of context of AIDS in sub-Saharan Africa. In I. O. Orubuloye, HIV and its implications in developing countries: From J. C. Caldwell, P. Caldwell, & G. Santow (Eds.), Sexual research to programs. 12th World AIDS conference, Geneva, networking and AIDS in sub-Saharan Africa (pp. 129–162). 28 June–03 July [abstract 23300]. Canberra: Health Transition Series No. 4. Australian Desclaux, A., & Raynaut, C. (1997). Le depistage VIH et le National University. conseil en Afrique au sud du Sahara: Aspects medicaux et Campbell Jr., C. H., Marum, M. E., Alwano-Edyegu, . M. G., sociaux. Paris: KARTHALA. Dillon, B. A., Moore, M., & Gumisiriza, E. (1997). The role Des Jarlais, D. C., Padian, N. S., & Winkelstein, W. (1994). of HIV counseling and testing in the developing world. Targeted HIV-prevention programs. The New England AIDS Education and Prevention, 9(Suppl. B), 92–104. Journal of Medicine, 331(21), 1451–1453. Campbell, C., Bussell, K., Fridlund, C., Gumisiriza, E., Iatesta, De Vincenzi, I. (1994). A longitudinal study of human M., Lartigue, K., MacGowan, R., Painter, T., Parker, K., immunodeﬁciency virus transmission by heterosexual part- Rayﬁeld, M., & Rugg, D. (2000). CDC global AIDS activity: ners. The New England Journal of Medicine, 331(6), Voluntary counseling and testing. Atlanta: CDC Global 341–346. AIDS Activities Technical Strategies, Draft 3/20/00. de Zoysa, I., Phillips, K. A., Kamenga, M. C., O’Reilly, K. R., Carael, M., Cleland, J., Deheneﬀe, J. C., Ferry, B., & Ingham, Sweat, M. D., White, R. A., Grinstead, O. A., & Coates, T. R. (1995). Sexual behavior in developing countries: implica- J. (1995). Role of HIV counseling and testing in changing tions for HIV control. AIDS, 9, 1171–1175. risk behavior in developing countries. AIDS, 9(Suppl. A), Carael, M., Cleland, J., & Ingham, R. (1994). Extramarital sex: S95–S101. Implications of survey results for STD/HIV transmission. de Zoysa, I., Sweat, M. D., & Denison, J. A. (1996). Faithful Health Transition Review, 4(suppl.), 153–172. but fearful: Reducing HIV transmission in stable relation- Carael, M., Van de Perre, P., Lepage, P., Allen, S., Nsengu- ships. AIDS, 10(Suppl. A), S197–S203. muremyi, F., Van Goethem, C., Ntahorutaba, M., Nzar- Diaby, L., Wiktor, S. Z., Ba, A., Sibailly, T. S., Ekpini, E. R., amba, D., & Clumeck, N. (1988). Human immunodeﬁciency Coulibaly, I. M., & Greenberg, A. (1996). Evaluation of an virus transmission among heterosexual couples in Central HIV counseling and testing program for pregnant women in Africa. AIDS, 2, 201–205. ˆ an antenatal clinic in Abidjan, Cote d’Ivoire. XI interna- Cartoux, M., Meda., N., Van de Perre, P., Newell, M. L., de tional conference on AIDS. Vancouver, 7–12 July [abstract Vincenzi, I., & Dabis, F. (1998). Acceptability of voluntary Th.C.4831]. HIV counseling and testing (VCT) and interventions to Diaby, K. L., Painter, T. M., Sibailly, T. S., Kouassi, K. M., reduce mother-to-child transmission of HIV in Africa. Lin, L., Roels, T., Ekpini, E. R., & Wiktor, S. Z. (2000). Ghent Working Group. 12th World AIDS conference, Obstacles to preventing mother-to-child transmission of Geneva, 28 June–03 July [abstract 23310]. HIV-1(MTC): HIV risk and prevention among pregnant Chaima, A., & Zimba, D. (1998). Cultural beliefs, barriers to ˆ women at a mother-child clinic in Abidjan, Cote d’Ivoire. sex discussion among married couples and its implications XIII World AIDS conference, Durban, 9–15 July 2000 in STD/HIV/AIDS prevention in Malawi. XII World [abstract ThPeC5331]. conference on AIDS. Geneva, 28 June–03 July [abstract Dube, S., Machekano, R., McFerland, W., & Mandel, J. (2000). 14213]. HIV voluntary counseling and testing of couples in Harare: Choi, K. H., & Coates, T. J. (1994). Prevention of HIV Problems and prospects. XIII World AIDS conference, infection. AIDS, 8, 1371–1389. Durban, 9–15 July 2000 [abstract TuPeD3773]. Coates, T., Coates, G., Sangiwa, G., Balmer, D., Furlonge, C., Edgar, T., Freimuth, V. S., Hammond, S. L., McDonald, D. Kamenga, C., & Gregorich, S. (1998). Serodiscordant A., & Fink, E. L. (1992). Strategic sexual communication: married couples undergoing couples counseling and testing Condom use resistance and response. Health Communica- reduce risk behavior with each other but not with extra- tion, 4(2), 83–104. marital partners. XII World conference on AIDS. Geneva, 28 XI International Conference on AIDS & STDs in Africa. June–03 July [abstract 33268]. (1999). Looking to the Future, Programme. XI international T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1409 conference on AIDS & STDs in Africa, 12–16 September, couples in Zaire. IX international conference on AIDS/IV Lusaka, Zambia. STD World Congress. Berlin, 6–11 June [abstract PO-C11- Ezeh, A. C. (1993). The inﬂuence of spouses over each other’s 2837]. contraceptive attitudes in Ghana. Studies in Family Plan- Kamb, M. L., Fishbein, M., Douglas Jr., J. M., Rhodes, F., ning, 24(3), 163–174. Rogers, J., Bolan, G., Zenilman, J., Hoxworth, T., Malotte, Farmer, P., Connors, M., & Simmons. J. (Eds.) (1996). Women, C. K., Iatesta, M., Kent, C., Lentz, A., Graziano, S., Byers, poverty and AIDS: Sex, drugs and structural violence. R. H., & Peterman, T. (1998). Eﬃcacy of risk- Monroe, Maine: Common Courage Press. reduction counseling to prevent human immunodeﬁciency Feldblum, P. J. (1991). Results from prospective studies of virus and sexually transmitted diseases. JAMA, 280(13), HIV-discordant couples. AIDS, 5, 1265–1277. 1161–1167. Feldblum, P., Hira, S., Godwin, S., Kamanga, J., & Mukelabai, Kamenga, M., Ryder, R. W., Jingu, M., Mbuyi, N., Mbu, L., G. (1992). Eﬃcacy of spermicide use and condom use by Behets, F., Brown, C., & Heyward, W. L. (1991). Evidence HIV-discordant couples in Zambia. VIII international of marked sexual behavior change associated with low HIV- conference on AIDS. Amsterdam, 19–24 July [abstract 1 seroconversion in 149 married couples with discordant WeC 1085]. HIV-1 serostatus: Experience at an HIV counseling center in Gerber, A. R., Campbell Jr., C. H., Dillon, B. A., & Holtgrave, Zaire. AIDS, 5, 61–67. D. R. (1994). Evaluating behavioral interventions: Need for Kashima, Y., Gallois, C., & McCamish, M. (1992). Predicting randomized control trials. (Comment). JAMA, 271(17), the use of condoms: Past behavior, norms, and the sexual 1317–1318. partner. In T. Edgar, A. Fitzpatrick, & V. S. Freimuth Gregorich, S., Kamenga, C., Sangiwa, G., Furlonge, C., & (Eds.), AIDS: A communication perspective (pp. 21–46). Balmer, D. (1998). Impact of HIV counseling and testing in Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.. three developing countries: Results from the voluntary HIV Kashima, Y., Gallois, C., & McCamish, M. (1993). The theory counseling and testing study. XII world conference on AIDS. of reasoned action and cooperative behavior: It takes two to Geneva, 28 June–03 July [abstract 33288]. use a condom. British Journal of Social Psychology, 32, 227– Hassoum, J. (1996). La solidarite familiale et communautaire a 239. l’epreuve du sida. Resultats d’une enquete aupres des femmes Keogh, P., Allen, S., Almedal, C., & Temahagili, B. (1994). The ˆte malades du sida a Abidjan (Co d’Ivoire). Communication social impact of HIV infection on women in Kigali, au Colloque Internationale organisee par CODESRIA, Rwanda: A prospective study. Social Science & Medicine, ORSTOM, CNLS-Senegal. Sciences sociales et sida en 38(8), 1047–1053. Afrique: Bilan et perspectives. Sali Portudal, Senegal, 4–8 King, R., Allen, S., Seruﬁlira, A., Karita, E., & Van de Perre, P. Novembre 1996. (1993). Voluntary conﬁdential HIV testing for couples in Heise, L. L., & Elias, C. (1995). Transforming AIDS prevention Kigali, Rwanda. AIDS, 7(10), 1393–1394. to meet women’s needs. A focus on developing countries. Ladner, J., Leroy, V., Msellati, P., Nyiaziraje, M., DeClerq, A., Social Science and Medicine, 40(7), 931–943. Van de Perre, P., & Dabis, F. (1996). A cohort study of Heyward, W. L., Batter, V. L., Malulu, M., Mbuyi, N., Mbu, factors associated with failure to return for post-test L., St Louis, M. E., Kamenga, M., & Ryder, R. W. (1993). counseling in pregnant women: Kigali, Rwanda, 1992– Impact of HIV counseling and testing among child-bearing 1993. AIDS, 20, 69–75. women in Kinshasa, Zaire. AIDS, 7(12), 1633–1637. Lainjo, B., Wawer, M. J., Lutalo, T., Sewankambo, N., & Higgins, D. L., Galavotti, C., O’Reilly, K. R., Schnell, D. J., Kelly, R. (1994). Use of HIV testing in rural Uganda. X Moore, M., Rugg, D. L., & Johnson, R. (1991). Evidence international conference of AIDS. Yokohama, 7–12 August for the eﬀects of HIV antibody counseling and testing on [abstract PDO 734]. risk behaviors. Journal of the American Medical Association, Larson, A. (1989). Social context of human immunodeﬁciency 266(17), 2419–2429. virus transmission in Africa: Historical and cultural bases of Holtgrave, D. R., Valdiserri, R. O., Gerber, A. R., & Hinman, East and Central African sexual relations. Reviews of A. R. (1993). Human immunodeﬁciency virus counseling, Infectious Diseases, 11(5), 716–731. testing, referral, and partner notiﬁcation services: A cost- Le Palec, A. (1994). Bamako, taire le SIDA. Psychopathologie beneﬁt analysis. Archives of International Medicine, 153, africaine, 26(2), 211–234. 1225–1230. Lurie, P., Hintzen, P., & Lowe, R. A. (1995). Socioeconomic Irwin, K. L., Valdiserri, R. O., & Holmberg, S. D. (1996). The obstacles to HIV prevention and treatment in developing acceptability of voluntary HIV antibody testing in the countries: The roles of the International Monetary Fund United States: A decade of lessons learned. AIDS, 10, 1707– and the World Bank. AIDS, 9(6), 539–546. 1717. Maman, S., Mbwambo, J., Hogan, M., Kilonzo, G., & Weiss, Jingu, M., Assina, Y., Mbuyi, K., Mbu, L., Mokwa, K., E. (2000). History of partner violence is common among Doppagne, A., & Ryder, R. (1990). High condom utilization women attending a voluntary counseling testing clinic in and low seroconversion rates successfully sustained in 175 Dar es Salam, Tanzania. XIII world AIDS conference, married couples in Zaire with discordant HIV serology: Durban, 9–15 July 2000 [abstract TuOrC308]. Observations after 2 years of follow-up. VI international Maposhere, C., Mashayamombe, S., Zhou, P., Ray, S., Van der conference on AIDS. San Francisco, 20–23 June [abstract Wijgert, J., Mason, P., & Katzenstein, D. (1996). Gender S.C.695]. political issues raised in HIV counseling of 200 couples in Jingu, M., Mbuyi, N., Ndilu, N., Assina, Y., & Musingayi, L. Zimbabwe. XI international conference on AIDS. Vancou- (1993). Impact of prolonged condom use in 178 discordant ver, 7–12 July [abstract Tu.D.2775]. 1410 T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 McGrath, J. W., Rwabukwali, C. R., Schumann, D. A., O’Reilly, K. R., & Piot, P. (1996). International perspectives on Pearson-Marks, J., Nakayiwa, S., Namande, B., Nakyobe, individual and community approaches to the prevention of L., & Mukasa, R. (1993). Anthropology and AIDS: The sexually transmitted diseases and human immunodeﬁciency cultural context of sexual risk behavior among urban virus infection. The Journal of Infectious Diseases,, Baganda women in Kampala, Uganda. Social Science and 174(Suppl. 2), S214–S222. Medicine, 36(4), 429–439. Orubuloye, I. O., Caldwell, J. C., & Caldwell, P. (1992). McKenna, S. L., Muyinda, G. K., Roth, D., Mwali, M., Diﬀusion and focus in sexual networking: Identifying Ng’andu, N., Myrick, A., Luo, C., Priddy, F. H., Hall, V. partners and partners’ partners. Studies in Family Planning, M., von Lieven, A. A., Sabatino, J. R., Mark, K., & Allen, 23(6), 343–351. S. A. (1997). Rapid HIV testing and counseling for Orubuloye, I. O., Caldwell, J. C., & Caldwell, P. (1993). African voluntary testing centers in Africa. AIDS, 11(Suppl. 1), women’s control over their sexuality in the era of AIDS. S103–S110. Social Science and Medicine, 37(7), 859–872. Moore, J., Van Devanter, N., Padian, N., Skurnick, J., Padian, N. S., O’Brien, T. R., Chang, Y. C., Glass, S., & Janowski, M., Bromberg, J., Cordell, J., & O’Brien, T. R. Francis, D. P. (1993). Prevention of heterosexual transmis- (1995). Women’s safer sex communications with sion of human immunodeﬁciency virus through couple male partners: A study of HIV-discordant couples. HIV counseling. Journal of Acquired Immune Deﬁciency Syn- infection in women conference, 22–24 February [abstract dromes, 6, 1043–1048. FA2-198]. Painter, T. M. (1996). The view from AIC: Input from AIC Moore, L., Padian, N., Shiboski, S., & O’Brien, T. R. (1991). counselors and management staﬀ on issues for consideration Behavior change in a cohort of heterosexual couples with in the initiative for discordant couples: Working Paper. one HIV-infected partner. VII international conference on Kampala: International Activity, Division of HIV/AIDS AIDS. Florence, 16–21 June [abstract W.C. 103]. Prevention, Centers for Disease Control and Prevention, Moore, L., & Padian, N. S. (1993). The social context of sexual Atlanta, Georgia & AIDS Information Centre, Kampala, 05 risk taking in a cohort of heterosexuals. IX international September. conference on AIDS/IV STD world congress. Berlin, 6–11 Painter, T., Sibailly, T., Diaby, K., Ekpini, E., Roels, T., & June [abstract PO-D15-3873]. Wiktor, S. (1998). A study of women’s decisions to participate Moore, M., Higgins, D., Nabwiso, F., Tukwasiibe, E., in HIV prevention interventions and in a clinical trial in Rwekikomo, F., Muzigirwa, W., Kabasharira, N., & ˆte ˆ Abidjan, Co d’Ivoire. Abidjan, Cote d’Ivoire and Atlanta: Taremwa, C. (1993). Evaluation of the AIDS information Projet RETRO-CI and the Centers for Disease Control and centre (AIC). Preliminary report of ﬁnal evaluation study Prevention. data. Draft Report, 15 January. Painter, T. M., Diaby, K. L., Sibailly, T. S., Agnissan, A. A., Morris, M., & Kretzschmar, M. (1997). Concurrent relation- Tirera, F., Toure, M. R., Kouassi, K. M., Lin, L. S., Fluker, ships and the spread of HIV. AIDS, 11, 641–648. D., Roels, T., Ekpini, E. R., & Wiktor, S. Z. (1999). Doing M’Pele, P., Lallemant-Le Coeur, S., Lallemant, M., & Samba, the right thing: Opportunities and obstacles to reducing L. (1991). Screening for HIV-1 infection in Africa: A mother-to-child HIV transmission among clients at a problem within a problem. VII international conference on ˆ mother-child clinic in Abidjan, Cote d’Ivoire. XI interna- AIDS. Florence, 16–21 June [abstract MD-4154]. tional conference on AIDS and STDs in Africa, Lusaka, 12– M’Pele, P., Lallemant-Le Coeur, S., & Lallemant, M. J. (1994). 16 September [abstract 15ET3-1]. AIDS counseling in Africa. In S. Mboup, P. J. Kanki, & M. Painter, T. M., Diaby, K. L., Sibailly, T. S., Dogore, E. M., R. Kalengayi (Eds.), AIDS in Africa (pp. 463–472). New McLellan, E., Lin, L., Roels, T., Ekpini, E. R., & Wiktor, York: Raven Press. S. Z. (2000). Using qualitative data to better Muller, O., Barugahare, L., Schwartlander, B., Byaruhanga, E., understand women’s decisions about HIV prevention. XIII Kataaha, P., Kyeyune, D., Heckmann, W., & Ankrah, M. world AIDS conference, Durban, 9–15 July 2000 [abstract (1992). HIV prevalence, attitudes and behavior in clients of WePeD4597]. conﬁdential HIV testing and counseling centre in Uganda. Pickering, H., Quigley, M., Pepin, J., Todd, J., & Wilkins, A. AIDS, 6(8), 869–874. (1993). The eﬀects of post-test counseling on condom use Mullick, S., Abdool Karim, Q., & Morar, N. S. (1998). among prostitutes in the Gambia. AIDS, 7, 271–273. Reducing women’s risk: Men the missing link? XII world Pivnick, A. (1993). HIV infection and the meaning of condoms. conference on AIDS. Geneva, 28 June–03 July [abstract Culture, Medicine and Psychiatry, 17, 431–453. 23160]. Rwabukwali, C. B., Schumann, D. A., McGrath, J. W., Nzegwu, F. (2000). Gender sensitive facilities. XIII world AIDS Carroll-Pankhurst, C., Mukasa, R., Nakayiwa, S., Na- conference, Durban, 9–15 July 2000 [abstract WePpE1357]. kyobe, L., & Namande, B. (1994). Culture, sexual behavior, Oakley, A., Fullerton, D., & Holland, J. (1995). Behavioural and attitudes toward condom use among Buganda women. interventions for HIV/AIDS prevention. AIDS, 9, 479–486. In D. A. Feldman (Ed.), Global AIDS policy (pp. 70–89). Obbo, C. (1993). HIV transmission: Men are the solution. Westport: Bergin and Garvey. Population and Environment, 14(3), 211–243. Sangiwa, G., Balmer, D., Furlonge, C., Grinstead, O., & Obbo, C. (1995). Gender, age and class: Discourse on HIV Kamenga, C. (1998). Voluntary HIV counseling and testing transmission and control in Uganda. In H. T. Brummelhuis, reduces risk behavior in developing countries: Results from & G. Herdt (Eds.), Culture and sexual risk: Anthropological the voluntary counseling and testing study. XII world perspectives on AIDS (pp. 79–96). Luxembourg: Gordon conference on AIDS, Geneva, 28 June–03 July [abstract and Breach Publishers. 33269]. T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1411 Seeley, J. A., Malamba, S. S., Nunn, A. J., Mulder, D. W., 12th World AIDS Conference. (1998). Bridging the gap: Kengeya-Kayondo, J. F., & Barton, T. G. (1994). Socio- Conference record. 12th World AIDS conference, 28 June– economic status, gender, and risk of HIV-1 infection in a 03 July, Geneva, Switzerland. rural community in south west Uganda. Medical Anthro- Ulin, P. R. (1992). African women and AIDS: Negotiating pology Quarterly, 8(1), 78–89. behavioral change. Social Science & Medicine, 34(1), 63–73. Serwadda, D., Gray, R. H., Sewankambo, N. K., & Wawer, M. UNAIDS/WHO. (1998). Report on the global HIV/AIDS J. (1994). Gender speciﬁc HIV transmission/ prevention in epidemic, June 1998. UNAIDS/WHO, Geneva, UNAIDS/ discordant couples in rural Uganda. X international 98.10 – WHO/EMC/VIR/98.2 – WHO/ASD/98.2. conference on AIDS, Yokohama, 7–12 August [abstract UNAIDS/WHO. (1999). AIDS epidemic update, December 107c]. 1999. UNAIDS/WHO, Geneva, UNAIDS/99.53E – WHO/ Serwadda, D., Gray, R. H., Wawer, M. J., Stallings, R. Y., CDS/EDC/99.9 – WHO/FCH/HSI/99.6 Sewankambo, N. K., Konde-Lule, J. K., Lainjo, B., & Van de Perre, P. (2000). Commentary: HIV voluntary counsel- Kelly, R. (1995). The social dynamics of HIV transmission ing and testing in community health services. Lancet, 356, as reﬂected through discordant couples in rural Uganda. 86–87. AIDS, 9, 745–750. van der Straten, A., Kin, R., Grinstead, O., Seruﬁlira, A., & Shaﬀer, N., Chuachoowong, R., Mock, P. A., Bhadrakom, C., Allen, S. (1995). Couple communication, sexual coercion Siriwasin, W., Young, N. L., Chotpitayasunondh, T., and HIV risk reduction in Kigali, Rwanda. AIDS, 9, 935– Chearskul, S., Roongpisuthipong, A., Chinayon, P., Karon, 944. J., Mastro, T. D., & Simonds, R. J. (1999). Short-course The Voluntary HIV-1 Counseling and Testing Eﬃcacy zidovudine for perinatal HIV-1 transmission in Bangkok, Study Group. (2000). Eﬃcacy of voluntary HIV-1 counsel- Thailand: A randomized controlled trial. Lancet, 353(9155), ling and testing in individuals and couples in Kenya, 773–780. Tanzania, and Trinidad: A randomized trial. Lancet, 356, Sweat, M. D., & Denison, J. A. (1995). Reducing HIV incidence 103–112. in developing countries with structural and environmental Waliggo, J. M. (2000). A woman confronts social stigma in interventions. AIDS, 9(Suppl. A), S251–S257. Uganda. In J. F. Keenan, J. D. Fuller, L. S. Cahill, & K. Sweat, M., Gregorich, S., Sangiwa, G., Furlonge, C., Balmer, Kelly (Eds.), Catholic ethicists on HIV/AIDS Prevention (pp. D., Kamenga, C., Grinstead, O., & Coates, T. (2000). Cost- 48–56). New York & London: Continuum. eﬀectiveness of voluntary HIV-1 counseling and testing in Wiktor, S. Z., Ekpini, E., Karon, J. M., Nkengasong, J., reducing sexual transmission of HIV in Kenya and Maurice, C., Severin, S. T., Roels, T. H., Kouassi, M. K., Tanzania. Lancet, 356, 113–121. Lackritz, E. M., Coulibaly, I. M., & Greenberg, A. E. Temmerman, M., Moses, S., Kiragu, D., Fusallah, S., Wanola, (1999). Short-course oral zidovudine for prevention of I. A., & Piot, P. (1990). Impact of single session post-partum mother-to-child transmission of HIV-1 in Abidjan, Cote ˆ counseling of HIV infected women on their subsequent d’Ivoire: A randomized trial. Lancet, 353(9155), 781–785. reproductive behavior. AIDS Care, 2, 247–252. Wolitski, R. J., MacGowan, R. J., Higgins, D. L., & Jorgensen, XIII International AIDS Conference. (2000). Breaking the C. M. (1997). The eﬀects of HIV counseling and testing on Silence, Abstracts, vols. 1 & 2. XIII international AIDS risk-related practices and help-seeking behavior. AIDS conference, 09–15 July, Durban, South Africa. Education and Prevention, 9(Suppl. B), 52–67. Turyagyenda, J., Agaba, B., Tumwine, J., Kalule, J., Baryar- The World Bank. (1999). Confronting AIDS: Public priorities in ama F., Aguti, E. F., & Namwebya, J. H. (1998). Planning a global epidemic. Washington. DC: The World Bank. for marriage and HIV counseling in Uganda. XII world Worth, D. (1989). Sexual decision-making and AIDS: Why conference on AIDS, Geneva, 28 June–03 July [abstract condom promotion among vulnerable women is likely to 43138]. fail. Studies in Family Planning, 20(6), 297–307. Turyagyenda, J. (2000). Planning for marriage and HIV counseling and testing in Uganda. XIII world AIDS conference, Durban, 9–15 July 2000 [abstract ThPeD3736].