|The Impact of Voluntary Counselling and Testing: A global review of the benefits and challenges (UNAIDS, 2000, 96 p.)|
In this review of VCT outcomes, the majority of studies reveal benefits following VCT. However, many of the studies are descriptive, without control groups and have end points that rely on reported behavioural data (such as number of sexual partners or condom use) that are not supported with more objective outcomes. In most of these studies there are, however, clear preliminary indicators that VCT is important in helping people reduce risky behaviour, although societal and cultural pressures may sometimes override these. VCT is also shown to be important in enabling PLHAto access appropriate services, make decisions about future and family planning and benefit from interventions to prevent HIV-associated infections and MTCT. VCT cannot prevent PLHA from the inevitable emotional stress when they learn about a seropositive result, but it can help people to understand, accept and cope. VCT services can also help those who test seronegative in future planning and in obtaining HIV preventive services to help them adopt and maintain safe sexual and injecting practices. There is, however, very little information on whether behaviour changes for both those who test seropositive and seronegative can be maintained in the long term.
Changing sexual behaviour following VCT is influenced by many factors and is easier if both partners can be counselled and tested together. Those studies that show the most consistent reduction in risky sexual behaviour are among couples who attended VCT together.
A small number of studies report adverse consequences following VCT (such as violence, abandonment and break-up of relationships) and many studies had anticipated that these would be difficulties. However, in the majority of studies these were rare and could be minimized by counselling, particularly about disclosure.
Most of the studies that are more rigorously designed and have more objective endpoints (such as seroconversion rates or STI rates) are from industrialized countries and among MSM and IDUs. Although many of these studies show significant reductions in risky behaviour, the results are not consistent. Other societal and behav-ioural factors may be important in determining sexual and injecting behaviour in these groups and results cannot be generalized to heterosexuals from developing countries.
When reviewing VCT studies it is difficult to make comparisons between the VCT interventions as these vary considerably between studies. In most studies the content and duration of the pre- and post-test counselling and the availability of ongoing counselling and support services were inadequately described. Although several studies show that VCT is superior to health education and in-depth counselling superior to brief information-giving, it is not known what the key elements are in VCT that are most important in motivating long-term behaviour change.
Denial, stigma and lack of openness about HIV are acknowledged as being major barriers to HIV prevention and care in many high-prevalence countries. Although it is postulated that increased availability and uptake of VCT can overcome these barriers there are no studies that have explored this, and this area is in urgent need of investigation.
Even though VCT does enable many people to change their behaviour not all are able to do so and not all VCT interventions are similarly successful in motivating behaviour change in different settings and among a wide range of populations. However, no single intervention (particularly HIV testing with a relatively brief pre- and post-test counselling) should be expected to influence complex long-term behaviour in all people. VCT should be flexible and may need specific adaptation for specific groups of people. It should also be part of a more comprehensive programme that provides ongoing HIV prevention education and information, starting with HIV and sexual health education for young people before they become sexually active and reinforced at other contacts with health workers. Innovative strategies are important to reach marginalized groups and groups who are not regularly in contact with formal health sector.
Important questions about the effective implementation of VCT remain unanswered. How can VCT services be improved to maximize the behavioural impact? Can VCT services be made less costly so that they can be implemented more widely in developing countries? What are the long-term outcomes following VCT? How can VCT services be adapted to provide supportive care and HIV prevention for sex workers and their clients and other marginalized groups? How can VCT services associated with MTCT projects include husbands/partners and will this improve uptake and influence sexual behaviour? Will the wider availability of VCT promote normalization and reduce stigma in communities? These questions should be considered when designing VCT evaluations, particularly in developing countries that have the greatest burden of HIV.