Voluntary counseling and testing for couplesahigh-leverage

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					                                      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: tcp2@cdc.gov (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
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