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

Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention, Division of HIV/AIDS Prevention-Surveillance and Epidemiology, Atlanta, GA 30333, USA.
Social Science & Medicine (Impact Factor: 2.89). 01/2002; 53(11):1397-411. DOI: 10.1016/S0277-9536(00)00427-5
Source: PubMed


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.

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Available from: Thomas M Painter
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    • "In Table 2 we list definitions of couples-testing defined by the World Health Organisation (WHO), whilst Fig. 1 summarizes different trajectories through which decisions were made. Painter emphasized the importance of ‘social interaction’ between both partners and a counselor within couple HIV testing and counseling [40]. Couples-HIVST, is, instead, highly heterogeneous and dictated by the nature of specific relationships, especially by the attitude of the man, emphasising the importance of gendered household relations to couples-HIVST. "
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    ABSTRACT: In sub-Saharan Africa, most new HIV infections occur in stable relationships, making couples testing an important intervention for HIV prevention. We explored factors shaping the decision-making of cohabiting couples who opted to self-test in Blantyre, Malawi. Thirty-four self-tested participants (17 couples) were interviewed. Motivators for HIV self-testing (HIVST) emerged at three main levels. Individual motivations included perceived benefits of access to treatment, and self-checking of serostatus in the hope of having been cured by prolonged treatment or faith-healing. HIVST was considered convenient, confidential, reassuring and an enabling new way to test with one's partner. Partnership motivations included both positive (mutual encouragement) and negative (suspected infidelity) aspects. For women, long-term health and togetherness were important goals that reinforced motivations for couples testing, whereas men often needed persuasion despite finding HIVST more flexible and less onerous than facility-based testing. Internal conflict prompted some partners to use HIVST as a way of disclosing their previously concealed HIV positive serostatus. Thus, the implementation of community-based HIVST should acknowledge and appropriately respond to decision-making processes within couples, which are shaped by gender roles and relationship dynamics.
    Full-text · Article · Jun 2014 · AIDS and Behavior
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    • "CVCT has been shown to be an efficacious HIV prevention strategy and findings suggest that it may be an appropriate and effective method for reducing transmission within male couples (Burton, Darbes, & Operario, 2010; El-Bassel et al., 2010). The World Health Organization (WHO) (2012) has issued guidance for implementing CVCT, which has been used effectively with heterosexual couples in Africa (Allen et al., 1992; Chomba et al., 2008; Farquhar et al., 2004; Guthrie, de Bruyn, & Farquhar, 2007; Painter, 2001), and findings suggest this is a promising strategy for prevention among MSM couples (Coates, 2000; Painter, 2001; Stephenson, Rentsch, & Sullivan, 2012a; Stephenson et al., 2011, 2012b). "
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    ABSTRACT: Main partnerships represent one context in which HIV transmission may occur that has been insufficiently addressed to date for gay and bisexual men, but few studies have focused on the acceptability of couples-based voluntary HIV counseling and testing (CVCT) for male couples in the U.S. Our aim in this study was to explore the acceptability of CVCT among a national U.S. sample of 1,532 gay and bisexual men surveyed online using a sexual networking site. We examined the role of demographic (i.e., geographic region, age, relationship status, sexual orientation, race/ethnicity) and HIV risk (i.e., substance use, number of sexual partners, unprotected anal intercourse, sexual role identity, and sexual compulsivity) factors that may be associated with CVCT among the full sample and among partnered men separately. We found that single men expressed higher interest in CVCT than partnered men and that greater age was more strongly associated with lower interest in CVCT for partnered men than for single men. The intersection of sexual orientation and race/ethnicity was also significantly associated with CVCT interest, with a higher proportion of Black bisexual men being interested than White bisexual men. These findings suggest that the uptake of CVCT may be less impacted by HIV risk factors than by demographic factors and that young gay and bisexual men of color-for whom rates of HIV continue to rise-may be the group with the highest levels of interest in CVCT.
    Full-text · Article · Nov 2013 · Archives of Sexual Behavior
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    • "A growing body of evidence shows that a large proportion of HIV infection occurs in marital or cohabiting relationships [1-4], for instance, 50-65% in Swaziland; 35-62% in Lesotho; and 44% in Kenya [4] and a high prevalence of discordant couples has been reported in some 12 sites of Eastern and Southern Africa [4]. Therefore, couple HIV testing has long been touted as essential for facilitating disclosure of HIV status in marital relationships [5,6]; adoption of risk reduction sexual behaviour [7-12]; uptake of treatment for prevention of mother-to-child transmission of HIV (PMTCT) [13,14]; and reduction in loss-to-follow up of women on treatment [14]. "
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    ABSTRACT: Background Couple HIV testing has been recognized as critical to increase uptake of HIV testing, facilitate disclosure of HIV status to marital partner, improve access to treatment, care and support, and promote safe sex. The Zambia national protocol on integrated prevention of mother-to-child transmission of HIV (PMTCT) allows for the provision of couple testing in antenatal clinics. This paper examines couple experiences of provider-initiated couple HIV testing at a public antenatal clinic and discusses policy and practical lessons. Methods Using a narrative approach, open-ended in-depth interviews were held with couples (n = 10) who underwent couple HIV testing; women (n = 5) and men (n = 2) who had undergone couple HIV testing but were later abandoned by their spouses; and key informant interviews with lay counsellors (n = 5) and nurses (n = 2). On-site observations were also conducted at the antenatal clinic and HIV support group meetings. Data collection was conducted between March 2010 and September 2011. Data was organised and managed using Atlas ti, and analysed and interpreted thematically using content analysis approach. Results Health workers sometimes used coercive and subtle strategies to enlist women’s spouses for couple HIV testing resulting in some men feeling ‘trapped’ or ‘forced’ to test as part of their paternal responsibility. Couple testing had some positive outcomes, notably disclosure of HIV status to marital partner, renewed commitment to marital relationship, uptake of and adherence to treatment and formation of new social networks. However, there were also negative repercussions including abandonment, verbal abuse and cessation of sexual relations. Its promotion also did not always lead to safe sex as this was undermined by gendered power relationships and the desires for procreation and sexual intimacy. Conclusions Couple HIV testing provides enormous bio-medical and social benefits and should be encouraged. However, testing strategies need to be non-coercive. Providers of couple HIV testing also need to be mindful of the intimate context of partner relationships including couples’ childbearing aspirations and lived experiences. There is also need to make antenatal clinics more male-friendly and responsive to men’s health needs, as well as being attentive and responsive to gender inequality during couselling sessions.
    Full-text · Article · Mar 2013 · BMC Health Services Research
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