Evaluation of a home-based voluntary counselling and testing
intervention in rural Uganda
BRENT WOLFF, BARBARA NYANZI, GEORGE KATONGOLE, DEO SSESANGA, ANTHONY RUBERANTWARI
AND JIMMY WHITWORTH
Medical Research Council, Entebbe, Uganda
Background: Uptake of HIV test results from an annual serosurvey of a population study cohort in rural
southwestern Uganda had never exceeded 10% in any given year since inception in 1989. An
intervention offering counselling and HIV results at home was conducted in four study villages
following the 2001 serosurvey round, and followed by a qualitative evaluation exploring nature of
demand and barriers to knowing HIV status.
Methods: Data from annual serosurveys and counsellor records are analyzed to estimate the impact of
the intervention on uptake of HIV test results. Textual data are analyzed from 21 focus group discussions
among counsellors, and men and women who had received HIV test results, requested but not yet
received, and never requested; and 34 in-depth interviews equally divided among those who had
received test results either from counselling offices and homes.
Results: Offering HIV results at home significantly increased uptake of results from 10 to 37% for all
adults aged 15 (p , 0.001), and 46% of those age 25 to 54. Previous male advantage in uptake of test
results was effectively eliminated. Focus group discussions and in-depth interviews highlight
substantial non-monetary costs of getting HIV results from high-visibility public facilities prior to
intervention. Inconvenience, fear of stigmatization, and emotional vulnerability of receiving results
from public facilities were the most common explanations for the relative popularity of home-based
voluntary counselling and testing (VCT). It is seen as less appropriate for youth and couples with
conflicting attitudes toward testing.
Conclusions: Home delivery of results revealed significantly higher demand to know HIV status than
stubbornly low uptake figures from the past would suggest. Integrating VCT into other services, locating
testing centres in less visible surroundings, or directly confronting stigma surrounding testing may be
less expensive ways to reproduce increased uptake with home VCT.
Key words: VCT uptake, HIV, home care, stigma, qualitative, clients, providers
Knowledge of HIV serostatus has been advocated as a
prerequisite for access to support and care (e.g. de Zoysa
et al. 1995) and increasingly as a prevention measure in its
own right (e.g. Summers et al. 2000; de Cock et al. 2002,
2003). Voluntary counselling and testing (VCT) remains the
most widely accepted approach for promoting knowledge of
serostatus. Research over the last decade has demonstrated
the public health benefit of VCT in terms of reductions in
risk behaviour that are both significant (Weinhardt et al.
1999; Voluntary HIV-1 Counselling and Testing Efficacy
Study Group 2000; Marks and Crepaz 2001) and cost-
effective (Sweat et al. 2000; Forsythe et al. 2002). WHO has
recently called for initiatives to increase access to
innovative, ethical and practical models of HIV testing
and counselling (WHO 2003). Since most individuals who
attend voluntarily to learn their HIV status will be
seronegative, VCT remains primarily a prevention and
education activity. While there is little evidence that
knowing status changes risk behaviour for those who test
negative, the benefits for those who test positive in terms of
risk reduction, counselling support and referral to other care
is compelling from research cited above. Negative con-
sequences of knowing status for individuals in the context of
stigma and inequality remain a real concern (Keogh et al.
1994; Temmerman et al. 1995; van der Straten et al. 1995;
Fylkesnes et al. 1999), but others have argued that these are
relatively rare and need to be balanced against positive
outcomes of knowing status (Maman et al. 2000; Grinstead
et al. 2001).
The question that now faces policy makers is whether
newfound enthusiasm for VCT at the research and policy
level will be matched by actual public demand to learn HIV
serostatus. In a recent national survey in Uganda, for example,
nearly two-thirds of adult men and women reported being
HEALTH POLICY AND PLANNING; 20(2): 109–116
Health Policy and Planning 20(2),
Q Oxford University Press, 2005; all rights reserved.
by guest on May 15, 2011
willing to test for HIV, although less than 6% had ever been
tested in the past (Uganda Bureau of Statistics and
ORC/Macro International Inc. 2001). Even in urban areas
where VCT services are widely available at subsidized cost,
only 20% had ever been tested in their lifetime. If ostensible
demand for VCT is so high, why is actual uptake so low even
within reasonable proximity to testing and counselling
Until the introduction of antiretroviral therapies, the net
benefit of knowing status was questionable enough to make
tepid demand the most likely explanation. DeCock and
colleagues (2002) suggest high standards for privacy and
counselling surrounding HIV testing act as a barrier in their
own right. Methods of service delivery may also play an
important independent role (see Irwin et al. 1996). Integration
of counselling and testing with routine clinic services such as
antenatal care (Cartoux et al. 1998; Msellati et al. 2001), TB
care (Godfrey-Faussett et al. 2002; Zachariah et al. 2003), and
primary health care (Pronyk et al. 2002; Peck et al. 2003) have
seen uptake increase to 60% or higher in some cases. In a
study cohort in Rakai district, Uganda, uptake of results
delivered at home rose from 35% in the first year of the study
in 1994–5 to 65% in 1999–2000 (Matovu et al. 2002). One-
time home delivery of HIV results and counselling following
community-wide mobilization in Mukono district of Uganda
yielded a remarkable 93% uptake (Were et al. 2003). Whether
high uptake figures reflect underlying demand any better than
low uptake figures is a valid question for research, as some
follow-up studies have found evidence of clients being
pressured to receive results or given insufficient information
to make informed choices (Temmerman et al. 1995; Abdool
Karim et al. 1998).
While it seems evident that services should be tailored to
demand, how can real demand be determined in field settings?
In this paper, we employ a mix of quantitative and qualitative
research methods to analyze the results of an intervention to
deliver HIV test results from an annual serosurvey at home in
a rural population cohort in southwestern Uganda.
Background for counselling services and the
home VCT pilot
In 1989 the Medical Research Council Programme on AIDS in
Uganda (MRC) established a population cohort to study the
dynamics of the HIV epidemic from social, epidemiological
and medical perspectives in 15 villages in rural southwestern
Uganda (Seeley et al. 1991). Once every year, survey teams go
from door to door to census the local population, conduct a
questionnaire interview and collect a blood sample for HIV
testing from all willing residents aged 13 and above following
written consent.1Participants are encouraged to obtain HIV
results from the serosurvey free of charge, but the decision to
obtain results is strictly voluntary. Blood samples are
transported twice a week to a testing facility at the Uganda
Virus Research Institute 3 hours away by road. All samples are
tested using two independent ELISAs. For positive, discordant
or ambiguous results, a testing algorithm designed to
minimize the number of indeterminate results is followed
involving repeat dual ELISAs and confirmatory Western Blots
(Nunn et al. 1993). Test results are then entered into a central
database, and those that have been specifically requested by
individuals are printed and returned to the field stations. The
entire process normally takes 1 month from the time of
bleeding, though interruptions at any stage of the process may
result in delays in results reaching the field. Free walk-in
counselling services are also available year-round to both
survey and non-survey participants.
Over the history of the cohort study, efforts have been made to
reduce the time and energy needed to access HIV test results.
From a single central counselling office opened in 1989,
services expanded to four field-counselling offices that were
opened in 1994. Since 1999, counsellors have been available
to give out HIV test results for 1 month after the serosurvey
from designated private homes in villages without permanent
counselling offices. Currently almost two-thirds of serosurvey
participants who ask for their results get them from such
private homes. The time required to walk to obtain results for
participants living in the remotest corner of the study area has
thus been reduced from 90minutes in 1989 to 15minutes or
less in 2000.
Records show a gradual increase in counsellor visits since the
initiation of the cohort study, but annual uptake of HIV results
has never exceeded 10% of those surveyed. The 1999
serosurvey found 20% of adults had ever tested for HIV.
While this is twice the level of uptake of HIV test results
reported for other rural areas of Uganda, it is still no better
than rates reported for urban areas, despite the fact that the
service is free and the decision to obtain results does not
require a separate blood draw (Uganda Bureau of Statistics
and ORC/Macro International Inc. 2001). In an effort to boost
uptake of HIV results, an intervention study was conducted in
four villages in 2001, asking serosurvey respondents directly if
they wanted to know their HIV test results and offering home
delivery of counselling and results as soon as they became
available. Although the process of getting results described
above is atypical in many ways of the situation outside the
research setting, we still employ the term ‘VCT’ in this
analysis since it incorporates the same key elements. We
discuss implications for generalizing results in the concluding
section of the paper.
Trends in VCT uptake prior to the intervention year are based
on questionnaire data collected during annual serosurveys.
VCT uptake for the year of the home delivery pilot is
calculated from counsellor records of those who received
results applied to denominators of the numbers who were bled
in the serosurvey for that year.2Rates for the year prior to the
home VCT intervention (2000–2001) are adjusted to include
only those aged 15 and above who also participated in the
2000 serosurvey round. This allows a more unbiased
comparison based on those who were bled in the previous
serosurvey round. Unlike serosurvey rates, home delivery
rates exclude any test results obtained outside the serosurvey
and are based on a shorter observation period corresponding to
the several months when counsellors were delivering results at
home. Both differences will tend to underestimate the true
Brent Wolff et al. 110
by guest on May 15, 2011
impact of the home delivery intervention in comparison with
uptake in prior years and make a significant effect of the
intervention harder to prove.
A qualitative evaluation of the home delivery pilot was carried
out to gather views on the perceived advantages and
disadvantages of home delivery of VCT. A series of 20
focus groups were conducted among those who had requested
to receive their results at home but had not yet received them,3
those who had requested and received results at home, and
those who had no record of ever receiving their HIV results
from the MRC Programme. Groups were further divided by
sex and broad age categories (under 21, 21–35, 45 and older).
A single focus group was conducted among counsellors to
obtain their views on comparative advantages and disadvan-
tage of home counselling. Group discussions among those
involved in the home VCT pilot were conducted between
December 2001 and January 2002. Those who had never
received results were interviewed several months later.
A total of 34 in-depth interviews were conducted among equal
numbers of individuals who had received serosurvey test
results from home and from a counselling facility in the most
recent round. As with focus group participants, in-depth
interview candidates were selected by research stafffrom a list
of eligible candidates provided by counsellors, who obtained
initial oral consent to participate. Interviewers were blind to
test results, and emphasized to respondents during a second
oral consent prior to interview that they would not ask to know
test results. Fieldwork was conducted from January to March
2002. Coding was done manually and summarized in over-
view charts created in MS-Word to facilitate comparison
across individuals and groups.
Figure 1 depicts the trend in numbers of participants receiving
their HIV results through counselling offices in the four pilot
villages in the 3 years leading up to the home delivery
intervention and the intervention year. Uptake in the year prior
to the intervention varied from 6 to 16% between villages.
After the home delivery pilot, uptake increased to between 30
and 42%, representing a two- to five-fold increase over uptake
in the previous year.
Table 1 compares VCT uptake rates in the four pilot villages
combined for the year prior to the home delivery intervention
and uptake rates from the home delivery intervention. A
dramatic and statistically significant increase in uptake of HIV
results rates was observed in the home delivery intervention
compared with the previous year. Adjusting to include only
those who participated in the serosurvey in consecutive
rounds, the percentage that agreed to receive their HIV test
results increased from 10.0% in the year prior to the
intervention to 36.7% of all age groups combined and 46%
in those aged between 25 and 54 during the intervention year,
the peak ages of HIV risk. The greatest proportional increase
is observed in the youngest age group (15–24), although this
remained the lowest in terms of absolute uptake at 26%.4
Observed increases in uptake of results were statistically
significant for each age group and all ages combined
(p , 0.001). Under the facility-based system, women
between ages 25 and 54 were 40% less likely than men of
the same age to come back for their test results (10% vs 18%,
p ¼ 0.06), but the gender gap in uptake was nearly eliminated
by the home delivery intervention (44% vs 49%, p ¼ 0.326).
Qualitative evaluation of the home delivery pilot
In focus group discussions, groups were asked about
motivations for wanting to know (or not to know) HIV
serostatus, reasons for low uptake prior to the introduction of
home delivery, and for the relative popularity of receiving
results at home. Subjects for in-depth interview were asked a
similar set of questions about the decision to obtain their
results and the actual experience of receiving them at home or
at the counselling office. Analysis of results is organized in
three broad themes corresponding to personal motivation to
know status, service constraints and social stigma
Personal motivation and fears of knowing HIV serostatus
A number of benefits of knowing status were mentioned by
different groups: getting early treatment for illness,5planning
for the future, reducing workloads, preventing further births
which are seen to accelerate the course of disease, and
allowing responsible individuals to take action to prevent
spreading the virus to others. Nevertheless, unwillingness or
fear to learn one’s own HIV serostatus was viewed as a
persistent common barrier to greater uptake of HIV test
results. Not surprisingly, such fears were expressed most often
and most powerfully among groups who had never received
their HIV serostatus results. Most commonly mentioned was
Figure 1. Percentage of annual serosurvey respondents aged 15
and over who reported receiving HIV test results in the previous year,
by study village
Evaluation of home-based VCT111
by guest on May 15, 2011
the fear that worry about the future alone would hasten poverty
and death by accelerating the course of the disease and making
it difficult to work and support their families even before ill-
health became a factor. For others, fear of knowing one’s
status emerged indirectly as a kind of fatalism that assumes
they are already HIV-positive:
As long as we are treated when we give our blood, we do
not want to know our results because we are not ready to
start worrying. Keep them for us in your offices. I’d rather
die not knowing the cause of my death. Just give us
treatment. We are not bothered about getting our results.
(FGD, women 45þ who never asked for results)
Mixed in with such personal fears were a startling variety of
misconceptions about how the counselling and testing system
works, considering the level of interaction with Programme
activities. Some imagined printed lists of names and test
results of individuals pinned on the wall of the counselling
office. Others doubted the validity of the tests since some who
publicly claim to test negative for HIV then fall sick or die
shortly afterwards. A few even suspected that counsellors
might change a positive test result to a negative one for a
sufficient amount of money. Others believed the Programme
makes money by selling blood for a profit. Such views were
again expressed most commonly among the groups who had
never received their HIV test results, and collectively carry the
sense of actively maintained rationales not to know HIV
If they dare bring the results to our homes, people will
decide to spend the whole day in their gardens so you will
not find them . . . People would hide from you. (FGD,
women 45þ who never asked for results)
Although HIV results are free of charge in the study area,
many non-monetary costs of using the existing facility-based
VCT services were highlighted in both focus group discus-
sions and in-depth interviews. Undoubtedly, the relative
popularity of home delivery of VCT was due in no small
part to its advantages in terms of travel distance, time and
general convenience of getting results. Older participants
admitted ‘laziness’ as a factor in not getting results. Women in
particular mentioned difficulty of finding time to leave the
home and effort required to maintain standards of dress and
appearance in public when results were offered from
Getting results at home saves me from bathing, wearing my
good dress and having to walk all the way to the
counsellors’ office in order to get my results. In fact,
the counsellor can even give me my results as I work in the
banana plantations so I do not have to leave my work half
done. (FGD, women 21–35, waiting for results)
Long, unpredictable waiting times to get results were another
commonly cited reason for low uptake in the past. Participants
complained that residents are discouraged if they build up the
courage to come for the requested status results, only to find
they are not yet available. By the time results do become
available, many worried they would no longer be valid. Home
delivery of results did not effectively reduce waiting time, but
shifted responsibility for rescheduling and delivering delayed
results from the individual to the Programme:
I asked for my results and kept going to the clinic to get
them, but I was told the results had not yet come. Later I
was tempted and I had sex with other partners so the results
are of no use to me. (FGD, men 21–35, waiting for results)
Table 1. Percentage, number and rate ratio of serosurvey participants receiving their HIV test results before and during the home delivery intervention,
by age group and sex, 4 pilot villages only
in both 2001
A (n) B (n) C (n) D (n)E ¼ D/C (%)F (n)G ¼ F/B (%)H ¼ G/E
aOf those bled in the 2000 serosurvey round and interviewed again in 2001, percentage who reported receiving their HIV results from any source in the
bOf those bled in the 2001 serosurvey round, percentage who received their HIV results during the subsequent home-delivery intervention.
cAll age-specific differences between home and facility-based uptake are statistically significant at p , 0.001.
dDifference in facility-based uptake between men and women is significant at a marginal level (p ¼ 0.06).
Brent Wolff et al. 112
by guest on May 15, 2011
Interestingly, many felt it was the Programme who benefited
most by people receiving their results; otherwise they would
not promote it to such an extent. Hence home VCT was seen as
a way of making the benefit from the testing process less one-
sided. As long as the Programme collected blood samples
from individuals at home, why not deliver results at home as
well? As the policy rationale for making VCT more accessible
shifts progressively from private interest to public health
good, the same logic may eventually apply to VCT uptake in
From the counsellors’ perspective, delivering HIV test results
at home held a number of advantages over the facility-based
system, but additional costs as well. Counsellors reported that
delivering results to four times as many people in the same
amount of time was gratifying and reinforced their pro-
fessional sense of mission. However, delivering results at
home also meant a lot more time, energy and fuel money to
reach scattered rural residences, and frustration when
participants were found away from their homes. Exact records
of fuel or number of visits were not kept, but counsellors
estimated roughly one out of every five home VCT
participants required multiple attempts to give back a single
test result. Occasionally, counsellors reported feeling vulner-
able giving results in unknown environments. They were
careful never to give results indoors as much for their own
safety as for the privacy of the client:
At times we work in a state of fear depending on what you
see. Like I once gave positive results to a girl [at her home].
what would happen next. Whether she had gone for a panga
[machete] or whip or whatever! (FGD, counsellors)
Social barriers to uptake of VCT
More than personal apprehension or service constraints, fears
of inadvertent disclosure or false rumours starting from being
seen at the counselling offices tended to dominate discussion
of reasons for low uptake of VCT in the past and reasons for
the relative popularity of home VCT. Through a process of
community consultation, counselling offices were established
in busy trading centres to make them more accessible. Besides
serving as a place to obtain free condoms, the only other
reason to go to a field office is to be counselled, tested or
receive HIV test results. In every group, it was agreed that
being seen entering or leaving such an office would be
interpreted as a sign that the person has reason to be worried
about their HIV status, whether from having a promiscuous
partner or being promiscuous themselves, and is therefore
probably infected. The same sentiment was echoed in in-depth
interviews. Those who went to counselling offices were also
aware their visits were being observed and that they then
become the subject of rumours. What distinguished them from
home-VCT clients is their decision not to care.
Interviewer: Were you worried about what people would
think about you when they saw you going to the counselling
Respondent: Yes, I was worried but I had no choice, I had
to go there. Some people worry a lot about that, but not me.
I decided as long as I know my own results, let them say
what they like. (IDI, office VCT, female aged 49)
Respondent: . . . We found many people at the shops where
the counselling office is located. . .
Interviewer: Did you worry about people seeing you on the
way to the counselling office or the way back?
Respondent: No. Whether they see you or not, they will get
to know if you are infected when you start getting sick. (IDI,
office VCT, male aged 42)
office was the prospect of leaving it after receiving results.
Discussion in all groups suggested most people mentally
prepare to be told they are HIV-positive before going in for
results. The thought of having to make the trip back home
without losing composure under those circumstances kept
many from going in the first place. Even if they managed to
remain calm on the surface, participants feared a kind of
emotional transparency that would allow others to guess their
status. It was even mentioned by counsellors themselves:
At times you see someone feeling so sad after getting
positive results . . . You see him recollecting himself and
drying the tears. You remain waiting for another person,
but it remains in your heart also. You also think of how he is
going to pass by those people [gathered outside]. (FGD,
At home, no one will see me crying. (FGD, women 21–35,
waiting for results)
Surprisingly, most participants were adamant that maintaining
privacy for discussion and hiding the true purpose of the visit
from others in the family or village was or would be relatively
easy. Private places for discussion could usually be found
outdoors, and because counsellors usually do not give out
results outside the offices, visits to homes might be explained
under other pretexts. None of the in-depth interview
participants who received results at home reported any
problem concealing either their results or even the purpose
of the counsellor visit from others in the household.
Presumably such discretion might be difficult to sustain if
home delivery became routine.
A key concern of the evaluation was that participants in
intervention villages may have felt some pressure to ask for
their test results through a simple willingness to appear
compliant at the time of interview. There was no evidence of
any coercion, however, either from in-depth interviews, focus
group discussions or uptake statistics. Focus group and in-
depth participants mentioned anxiety and fears about the
future in the period between asking for results and getting
them, but no regret. Records of requests kept by counsellors
suggest over 80% of those who requested results eventually
received them.6In a typical village where 100 individuals
requested their results be delivered at home, 90 received them,
Evaluation of home-based VCT 113
by guest on May 15, 2011
five had moved away from the area, three asked for their
results to be taken back to the office (and never came to pick
them up) and two asked not to receive them at all.
Home VCT was not viewed as an improvement by all groups,
such as couples with discordant desire to receive results. The
possibility of marital disruption if a spouse found that his or
her partner was positive was often mentioned. Examples were
given about husbands who refused to let their wives go for
results in order to avoid inevitable arguments about who is
responsible in case of HIV-positive results.
Respondent: I prefer the office because I know my way of
Interviewer: Why don’t you want to receive them at home?
Respondent: Aaa-aah, you also know that when the
husband sees you asking for results, he says that it is
because you are promiscuous which will lead to a quarrel.
(IDI, office VCT, female aged 49, married)
The difficulty in receiving results at home is that if my wife
asked for her results alone and they are brought home, I
must ask her what her status is. If she refuses to let me
know, that would be reason enough for me to beat her
because it would mean that she is HIV-positive. (FGD, men
45þ who never asked for results)
Youth represent another group where benefits of home-based
VCT must be balanced against increased domestic conflict.
Somewhat in contrast to service statistics suggesting that
youth benefited proportionally more than any group by home
delivery, discussions among youth were unequivocal that the
appearance of a counsellor at the home by itself would invite
speculation or prying questions from parents or other family
members. Youth feared parents might demand to know their
status and withdraw support if HIV-positive results were
Getting results at home is only good for those living in their
own homes but not good for children that are still under
their parents’ control . . . ‘Tell us your status’ the parents
will demand. Alternatively, such children could decide to
branch off to the counsellor’s office on their way to school.
(FGD, youths waiting for results)
If I stealthily gave my blood and results that are brought
home show that I have the virus, my parent will stop
trusting me. He might stop paying my school fees when
he gets to know that I have silimu [AIDS]. However if I
go to the office and get to know my results all alone, I
keep the results to myself and my parents will keep
paying my school fees. (FGD, youths who never asked for
Fears of returning from the clinic with an HIV-positive result,
marital disruption and child abandonment reflect a surprising
degree of residual stigma in the study community despite
years of education and outreach services.
Despite concerted efforts over 10 years to improve access to
VCT services, less than 10% of participants in an annual
serosurvey in rural southwest Uganda return to get their HIV
results on an annual basis, and only 20% had ever received
their results under the existing facility-based system. A pilot
study of home delivery of HIV test results increased uptake
of HIV results 3 to 4 times or more for both sexes and all
In a qualitative investigation carried out after the intervention
study, the relative popularity of home VCT and reasons for
low uptake under the facility-based system were explained by
a combination of personal fears, service constraints and social
barriers to access. Among service constraints, home delivery
was predictably preferred in terms of travel time, distance and
effort required to obtain results. While home delivery of
results was no faster than facility-based delivery, it guaranteed
they would arrive as soon as they were available without the
risk of finding results were not yet available. We found no
evidence that increased uptake through home delivery of
results reflected any overt or implicit pressure from the
Programme; very few refused to receive the results they had
requested, and none of those interviewed regretted their
If the preference for home VCT for reasons of time and
convenience was expected, the role of social barriers in
explaining the relative popularity of home delivery was not.
Uganda has received praise for rising above the stigma
surrounding HIV/AIDS on a national policy level at an early
stage of the epidemic, to welcome research, advocacy and
public discussion of the problem (e.g. Malcolm and Dowsett
1998). The study site where the home delivery of VCT pilot
study was conducted has been the target of continuous HIV/
AIDS education outreach efforts for over a decade. Conse-
quently, it was surprising to learn the extent to which fears
over being identified as HIV-positive continue to discourage
study area residents from asking for their test results. Getting
results at home allowed area residents to know their status
without the risk of disclosing it to others in the process. It was
fear of the walk home after counselling more than any other
single factor that dominated explanations for the remarkable
relative popularity of home VCT in this setting. Whether
similar results would be reproduced outside the unique
conditions of a long-term study cohort may be debated.
There are no added benefits to participants from knowing test
results after agreeing to give initial blood samples. At the time
of this study, antiretroviral therapy was not available through
the study programme, though early access to routine treatment
through the programme was cited by participants as an
advantage of knowing their status. It is impossible to know the
net effect of cumulative sensitization efforts on demand to
know results. Ironically, raising public visibility of testing
might have made it a lightening rod for residual stigma about
AIDS. Given the comparable quantitative impact of home
VCT cited elsewhere in the literature, it seems most likely that
the effect of delivering HIV results at home, and the social
dynamics that underlie it, would not be unique to our own
Brent Wolff et al.114
by guest on May 15, 2011
Home VCT is undeniably an expensive option for an
intervention that still faces questions about its efficacy and
social consequences. Nevertheless, more generalizable les-
sons might be learned from this intervention study for all
VCT programmes. The first point worth reiterating is that low
uptake of VCT should not necessarily be interpreted as lack
of demand to know results. Secondly, no one mode of
delivery will suit the varied needs of the broad population.
Home counselling appears to work better for most people in
this setting, but others will continue to prefer office-based
VCT, while others such as youth might prefer more
anonymous settings away from both home or office. Thirdly,
convenience is important, but must be balanced against social
stigma considerations. Dedicated HIV counselling offices
should be located away from busy centres or allow
unobserved access. Particularly in rural areas where full
anonymity is not feasible under any system of delivery,
efforts to scale up VCT services should take advantage of
integrating testing into other services that provide clients a
safe pretext to visit.
Ultimately, efforts to disguise VCT services through home
delivery or integrating VCT into other health services may
succeed precisely because they pander to the existing
stigma surrounding HIV/AIDS. Breaking the silence around
testing and encouraging public disclosure of the act of
testing itself (but not necessarily individual HIV test results)
might address the root problem of HIV stigma that still
persists even in relatively progressive environments such as
Uganda. Perhaps the relative success in getting people to
know their status by routinizing of testing in Rakai, or
encouraging entire families to test in the Mukono example,
really lies in taking away the stigma attached to HIV testing
1Conditions identified by medically qualified interview staff are
treated or referred at the time of interview. Participants are given free
treatment for opportunistic infections or other common illnesses
throughout the year from the MRC field clinic. At the time of this
study, anti-retroviral therapy was not yet available through the MRC
clinic or local government health services.
2Counsellor records are kept separately from the longitudinal
serosurvey database, socharacteristics of individuals accepting results are
limited to village, age and sex.
3The distinction between those who had only requested and those
who had received results was made because it was assumed that
knowledge of personal HIV results might influence perception of the
intervention programme itself.
4Relatively low uptake among youth may be partly explained by the
fact that roughly 40% report never having sex. Because counselling
records cannot be linked to sexual behaviour data, nor can we be certain
that all those who requested their status were sexually active at the time,
these figures cannot be adjusted to exclude those who have never had sex.
5Antiretroviral therapy was notoffered through theMRC until2004,
although all study participants had access to care for opportunistic
infections and other common illnesses through the MRC field clinic
throughout the year.
6Request rates are reported only approximately since records of
requests were not available by age and sex for all pilot villages, and hence
could not be validated for this analysis.
Abdool Karim Q, Abdool Karim SS, Coovadia HM, Susser M. 1998.
Informed consent for HIV testing in a South African hospital: is it
truly informed and truly voluntary? American Journal of Public
Health 88: 637–40.
Cartoux M, Meda N, Van de Perre P et al. 1998. Acceptability of
voluntary HIV-testing by pregnant women in developing countries:
an international survey. Ghent International Working Group on
Mother-to Child Transmission of HIV. AIDS 12: 2489–93.
De Cock K, Marrum E, Mbori-Ngacha D. 2003. A serostatus-based
approach to HIV/AIDS prevention and care in Africa. The Lancet
De Cock K, Mbori-Ngacha D, Marum E. 2002. Shadow on the continent:
public health and HIV/AIDS in Africa in the 21st century. The
Lancet 360: 67–72.
De Zoysa I, Phillips KA, Kamenga MC et al. 1995. Role of HIV
counselling and testing in changing risk behaviour in developing
countries. AIDS 9 (Suppl A): S95–101.
Forsythe S, Arthur G, Ngatia G et al. 2002. Assessing the cost of
willingness to pay for voluntary HIV counselling and testing in
Kenya. Health Policy and Planning 17: 187–95.
Fylkesnes K, Haworth A, Rosensvard C, Kwapa PM. 1999. HIV
counselling and testing: overemphasizing high acceptance rate a
threat to confidentiality and the right not to know. AIDS 13:
Godfrey-Faussett P, Maher D, Mukadi YD et al. 2002. How human
immunodeficiency virus voluntary testing can contribute to
tuberculosis control. Bulletin of the World Health Organization
Grinstead OA, Gregorich SE, Choi KH, Coates T. 2001. Voluntary HIV-1
Counselling and Testing Efficacy Study Group. Positive and
negative life events after counselling and testing: the Voluntary
HIV-1 Counselling and Testing Efficacy Study Group. AIDS 15:
Irwin KL, Valdiserri RO, Holmberg SD. 1996. The acceptability of
voluntary HIV antibody testing in the United States: a decade of
lessons learned. AIDS 10: 1707–17.
Keogh P, Allen S, Almedal C, Temahagili B. 1994. The social impact of
HIV infection on women in Kigali, Rwanda: a prospective study.
Social Science and Medicine 38: 1047–53.
Malcolm, A., Dowsett, G (eds). 1998. Partners in prevention:
international case studies of effective health promotion practice in
HIV/AIDS. UNAIDS 98.29. At: [http://www.unaids.org/html/pub/
publications/irc-pub01/]. Accessed 7 March 2004. Geneva:
Maman S, Campbell J, Sweat M, Gielen A. 2000. The intersections of
HIV and violence: directions for future research and interventions.
Social Science and Medicine 50: 459–78.
Marks G, Crepaz N. 2001. HIV-positive men’s sexual practices in the
context of self-disclosure of HIV status. Journal of Acquired
Immune Deficiency Syndrome 27: 79–85.
Matovu JK, Kigozi G, Nalugoda F, Wabwire-Mangen F, Gray RH. 2002.
The Rakai Project counselling programme experience. Tropical
Medicine and International Health 7: 1064–7.
Msellati P, Hingst G, Kaba F et al. 2001. Operational issues in pre-
venting mother-to-child transmission of HIV-1 in Abidjan, Cote
d’Ivoire, 1998–99. Bulletin of the World Health Organization 79:
Nunn AJ, Biryahwaho B, Downing RG et al. 1993. Algorithms for
detecting antibodies to HIV-1: results from a rural Ugandan cohort.
AIDS 7: 1057–61.
Peck R, Fitzgerald DW, Liautaud B et al. 2003. The feasibility, demand,
and effect of integrating primary care services with HIV voluntary
counselling and testing: evaluation of a 15-year experience in Haiti,
1985–2000. Journal of Acquired Immune Deficiency Syndrome 33:
Pronyk PM, Kim JC, Makhubele MB et al. 2002. Introduction of
voluntary counselling and rapid testing for HIV in rural South
Africa: from theory to practice. AIDS Care 14: 859–65.
Evaluation of home-based VCT 115
by guest on May 15, 2011
Seeley J, Wagner U, Mulemwa J, Kengeya-Kayondo JF, Mulder DW.
1991. The development of a community based HIV/AIDS service in
a rural area of Uganda. AIDS Care 3: 207–17.
Summers T, Spielberg F, Collins C, Coates T. 2000. Voluntary
counselling, testing, and referral for HIV: new technologies,
research findings create dynamic opportunities. Journal of Acquired
Immune Deficiency Syndrome 25 (Suppl 2): S128–35.
Sweat M, Gregorich S, Sangiwa G et al. 2000. Cost-effectiveness of
voluntary HIV-1 counselling and testing ain reducing sexual
transmission of HIV-1 in Kenya and Tanzania. The Lancet 356:
Temmerman M, Ndinya-Achola J, Ambani J, Piot P. 1995. The right not
to know HIV-test results. The Lancet 345: 969–70.
Uganda Bureau of Statistics and ORC/Macro International Inc. 2001.
2001 Uganda Demographic and Health Survey. Entebbe and
Calverton, MD: UBOS and Macro International.
van der Straten A, King R, Grinstead O, Serufulira A, Allen S. 1995.
Couple communication, sexual coercion, and HIV risk reduction in
Kigali, Rwanda. AIDS 9: 935–44.
Voluntary HIV-1 Counselling and Testing Efficacy Study Group. 2000.
Efficacy of voluntary HIV-1 counselling and testing in individuals
and couples in Kenya, Tanzania, and Trinidad: a randomised trial.
The Lancet 356: 103–12.
Weinhardt LS, Carey MP, Johnson BT, Bickham NL. 1999. Effects of
HIV counseling and testing on sexual risk behavior: a meta-analytic
review of published research, 1985–1997. American Journal of
Public Health 89: 1397–405.
Were W, Mermin J, Bunnell R, Ekwaru JP, Kaharuza F. 2003. Home-
based model for HIV voluntary counselling and testing. The Lancet
WHO. 2003. The right to know: new approaches to HIV testing and
counselling. WHO/HIV/2003.08. Geneva: World Health Organiz-
Zachariah R, Spielmann MP, Harries AD, Salaniponi FL. 2003.
Voluntary counselling, HIV testing and sexual behaviour among
patients with tuberculosis in a rural district of Malawi. International
Journal of Tuberculosis and Lung Disease 7: 65–71.
We would like to dedicate this article to the memory of our co-author
George Katongole, who provided energetic and effective leadership for
MRC community development activities from 1990 to the time of his
death in 2003, and was a particularly strong advocate for the idea of
delivering HIV test results at home. He is missed by colleagues and
Brent Wolff has a Ph.D in sociology from the University of Michigan, has
lectured at Makerere University, Uganda (1994–96), and London School
of Hygiene and Tropical Medicine (1996–2001) before joining the
Medical Research Council Programme on AIDS in Uganda as the social
science project leader.
Barbara Nyanzi, BA, is a social science research associate with the MRC.
She led the fieldwork for the current study and contributed to qualitative
data analysis and writing.
George Katongole served as Community Development project leader for
the MRC from 1990 through 2003 at the time of his death. He actively
promoted the home VCT intervention and contributed to analysis of
quantitative data and writing.
Deogratias Ssessanga currently serves as Community Development
Project leader for the MRC. He contributed to implementation of the
home VCT intervention, analysis of quantitative and qualitative data, and
Anthony Ruberantwari, BStat, is a statistician with the MRC. He
managed the quantitative data and contributed to its analysis and writing.
Jimmy Whitworth, MD, is head of International Activities at the
Wellcome Trust. Previously he was Professor of International Public
Health at the London School of Hygiene and Tropical Medicine, and a
former head of programme for the MRC Programme on AIDS in Uganda
(1995–2003). He suggested the idea of a qualitative evaluation of the
home delivery intervention and contributed to writing and editing of the
Correspondence: Brent Wolff, Medical Research Council, P.O. 49,
Entebbe, Uganda. Tel: þ 256-41-320-042;
Brent Wolff et al. 116
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