Elsevier

Social Science & Medicine

Volume 53, Issue 11, December 2001, Pages 1397-1411
Social Science & Medicine

Voluntary counseling and testing for couples: a high-leverage intervention for HIV/AIDS prevention in sub-Saharan Africa

https://doi.org/10.1016/S0277-9536(00)00427-5Get rights and content

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.

Section snippets

HIV/AIDS in sub-Saharan Africa

23.3 million persons in sub-Saharan Africa were living with HIV infection or AIDS by the end of 1999, accounting for nearly 70% of the estimated 33.6 million individuals living with HIV/AIDS worldwide (UNAIDS/WHO, 1999). The vast majority of these persons were infected during heterosexual intercourse (Allen et al., 1992b; Berkley, 1994). During 1999 nearly 90% of the 571,000 children born or infected with HIV-1 through breast-feeding were living in sub-Saharan Africa. The mothers of these

Media-based interventions

Broad-based HIV/AIDS information programs, be they referred to as Information Education and Communication (IEC) or Communications for Behavior Change, and which use the electronic and (to a lesser extent) printed media to promote HIV/AIDS awareness and behavior change, have been common in sub-Saharan Africa since the mid-1980s. Typically these programs are directed toward an undifferentiated public or categories of individuals that are identified as more inclined to engage in higher-risk sexual

VCT studies and interventions from 1990 to 1997

VCT has received considerable scrutiny in the scientific literature during the 1990s. Reviews (e.g., Beardsell, 1994; Beardsell & Coyle, 1996; Campbell et al., 1997; Choi & Coates, 1994; Gerber, Campbell, Dillon, & Holtgrave, 1994; Higgins et al., 1991; Irwin, Valdiserri, & Holmberg, 1996; Oakley, Fullerton, & Holland, 1995; Wolitski, MacGowan, Higgins, & Jorgensen, 1997) and studies in African and non-African settings have assessed the effectiveness of VCT in reducing risk behaviors and

Accumulating evidence that VCT works and is cost-effective

Studies in sub-Saharan Africa during the 1990s produced evidence indicating, albeit somewhat inconsistently, 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 was particularly strong in the case of HIV serodiscordant couples. Regardless of study results, however, investigators were nearly unanimous in noting that VCT for couples may be a

Intervention processes

Strengthen VCT procedures, staff capacity & performance Target couples in VCT recruitment efforts. The prevention potential of VCT for couples in Africa can be realized only if more couples learn about and gain access to VCT. Components of a more specialized VCT package for couples would include:

  • Frequent, clear and accurate media-based information programs using multiple languages are needed to increase access to information on VCT, with particular attention to the importance of VCT for couples for preventing both heterosexual and mother–child HIV transmission.

  • Community outreach to couples in areas surrounding VCT facilities. This interactive approach is needed as a follow-on and complement to media-based information programs. Specific approaches need to be developed through pilot

Conclusion

This paper has provided a brief overview of results from recent research and HIV prevention interventions in sub-Saharan that focus on couples and HIV risks, VCT, and in particular, VCT for couples. It has been proposed that the growing body of research and program evidence from sub-Saharan Africa which is supportive of VCT for couples as a HIV prevention tool, together with an increasingly supportive international policy environment for VCT, have created a unique sociological conjuncture for

Acknowledgements

The author wishes to thank Carl Campbell, Tim Dondero, Lynda Doll and several anonymous reviewers for their helpful comments on earlier drafts of this paper, however the author accepts sole responsibility for the form and content of the current version. The views expressed herein are those of the author alone and do not necessarily reflect those of the Centers for Disease Control and Prevention.

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