|The Impact of Voluntary Counselling and Testing: A global review of the benefits and challenges (UNAIDS, 2000, 96 p.)|
In many settings HIV counselling is available without testing. This option is cheaper and does not require a laboratory infrastructure and distribution system for test kits and has the potential to reach large numbers of people.
In rural Uganda a community-based counselling service was established to offer HIV counselling without testing (Mugula et al., 1995245). Attendance rose from 80 per month in 1993, to 400 per month in 1995. Counselling centred on safer sex advice and condoms were distributed by the project. Uptake of condoms also increased considerably during this period.
In other settings where HIV counselling is offered without testing this can lead to client frustration since clients who following counselling are eager to be tested.
Astudy from the United States showed that the type of counselling given was important in HIV prevention. The study looked at the effect of brief and focused motivational/skills-building, HIV risk-reduction counselling versus educational coun-selling. They found that condom use rose from 22-66% (90 days after counselling) in the former group compared with 27-43% in the latter group (Kalichman et al., 1998246).
Other behavioural interventions
There have been several studies looking at the efficacy of behavioural interventions without HIV testing to reduce HIV risk behaviour. Three studies have shown beneficial outcomes of these interventions (measured as reductions in the incidence of STIs).
The most successful behavioural intervention trial described is in ethnic minority women in the United States (Shain, 1999247). Six hundred and seventeen women with STIs were recruited and randomized to receive either group counselling (three weekly sessions of three to four hours) or a fifteen-minute health talk with a nurse. The women who received the group counselling had a 37% reduction in STIs compared with the health education group over a 12-month period.
A randomized controlled study from the United States showed that brief group counselling reduced HIV-risk behaviour and resulted in better knowledge about HIV, stronger intentions to adopt safer sex and lower numbers of reported STIs among low-income women (Carey et al., 1998248).
In a study from the United Sates, 5 758 seronegative people who attended an STI clinic were randomly allocated into 3 groups to assess the efficacy of counselling in promoting safer sex behaviour (Kamb et al., 1998 Project RESPECT249). The first group received in-depth enhanced counselling, the second received brief counselling and the third a brief didactic message that was typical of the normal care given by the clinics. In the first two groups receiving counselling a personalized risk-reduction plan was discussed. The participants were interviewed and examined at 6 and 12 months. Those who had received counselling (both enhanced and brief) had 30% fewer STIs at 6 months and 20% fewer STIs at 12 months than those who had received the information alone. Reported condom use was also consistently higher in the counselling groups. The study took place at five sites and the results were consistent over all sites.
Some studies have shown increased reported condom use but no significant differences in STI rates:
Atrial among high-risk clients from 37 clinics in the United States showed that those who participated in a small group, 7-session HIV risk-reduction programme were more likely to use condoms consistently over a 12-month follow-up when compared with a control group. However, there was no significant difference in STI rates (NIMH, 1998250).
In a trial from an STD clinic in London, MSM either attended a seven-hour workshop or were given a twenty-minute session with a counsellor (Imrie et al., 1999251). Results showed that while there was a small increase in condom use there was no reduction in STIs.