|The Impact of Voluntary Counselling and Testing: A global review of the benefits and challenges (UNAIDS, 2000, 96 p.)|
Many approaches to HIV prevention and care require people to know their HIV status. The importance of voluntary counselling and testing (VCT) has brought about the wider promotion and development of VCT services. However, since the majority of countries where HIV has a major impact are also the poorest, the lack of resources has meant that VCT is often still not widely available in the highest-prevalence countries. For VCT services to be prioritized and for resources to be provided for their development, demonstrating the effectiveness of VCT is essential. One of the difficulties in evaluating VCTs effectiveness is the complexity of the VCT process and the wide range of possible outcomes. The term VCT has also been used in many contexts to cover a broad spectrum of interventions. In this article it includes interventions that comprise a minimum of pre- and post-test counselling associated with testing. However, it acknowledges that many VCT services offer ongoing/supportive counselling.
This paper examines the diverse roles of VCT, considers the various outcomes of VCT that can be evaluated and discusses the limitations and difficulties associated with VCT evaluation.
Drawing on published and unpublished literature, conference abstracts and case studies, this paper concentrates on information from developing countries. While some examples from industrialized countries are mentioned, this information is not exhaustive, hence review articles providing more complete information are cited.
Box 1: The goals of VCT
1. Prevention of HIVtransmission
From +ve tested people to untested or -ve partners
2. Prevention of HIVacquisition
By -ve tested people from +ve or untested partners
3. Early and appropriate uptake of service
· Medical care (including ARV therapy, treatment of OIs, prevention of OIs and HIV-associated infections and screening for HIV-associated infections and tumours
· Emotional care
4. Societal benefits
· Normalization of HIV
5. Counselling for adherence
· Adherence to ARVs and preventive therapies
· Counselling about adherence in MTCT interventions
Limitations of this review
VCT services, which are available for many different groups of people in various settings, vary greatly in their aims. This makes comparing VCT interventions difficult and sometimes misleading. The challenges of comparing interventions are summarized in Box 2.
Box 2: The challenges of comparing VCT interventions
- Different interventions
The content and quality of VCT services offered within and across countries vary considerably. It may therefore be inappropriate to compare in-depth, long-term counselling services, where follow-up social and medical support is provided, for example, with routine VCT associated with STI clinics, where such services are not available.
Factors that may influence outcomes of VCT interventions
· Theoretical framework of counselling
- Different populations
Differences in impact and outcomes will be expected when assessing VCT interventions in different populations. In industrialized countries, many of the studies looking at VCT and sexual behaviour change have been carried out among IDUs, homosexual men and attenders at sexually transmitted infection clinics. In sub-Saharan Africa, the majority of studies have been among the general population attending VCT centres, women attending antenatal clinics and among sex workers. It is difficult to make comparisons between these groups as patterns and determinants of behaviour vary considerably.
- Time considerations
Timing of evaluation in the development of the service
Many operational VCT projects are evaluated when they are established, and research projects may set up VCT services to specifically look at their impact. This means that evaluations often take place before services have been fully developed or before communities have become accustomed to the intervention or realized its possible benefits. This is particularly important in countries where VCT is a new service or where coun-selling has not previously been a component of medical care and support.
If the evaluation is repeated when services are well established, different outcomes may be achieved. For example, when setting up the first VCT service in Lusaka, Zambia many people who attended during the first two years were symptomatic and therefore the seropositivity rate of attenders was very high (>60%). People, at this stage, attended for testing to confirm what they suspected or they were referred by health care workers, friends or relatives who worried that they might have HIV. As the service developed and people became more aware of VCTs role in HIV prevention, the seropositivity rate among attenders fell to <25%. Many asymptomatic young people wished to know their HIV status and there was less stigma associated with testing. Furthermore, as accessible treatments became available people were less reluctant to be tested since they felt there was something that could be offered if they tested positive (Kara).
In Uganda the population seeking VCT has also changed over time. In 1992 66% of clients were male. By 1997 more women were seeking VCT and the proportion of men had fallen to 51%1. Seropositivity rates of attenders also changed; in 1990 35% of female and 23% of male attenders were seropositive. By 1998 seropositivity rates of attenders had dropped to 26% for females and 14% for males.
Maturity and magnitude of the epidemic
The maturity of the epidemic may have an important impact on outcomes. This is particularly true for uptake and return rates. In areas where the epidemic is new, ignorance, denial and stigma may be more closely associated with HIV testing than in countries where the epidemic is more well established.
Countries where the epidemic is mature may also be experiencing a great impact from HIV in terms of morbidity and mortality and other sequelae such as rising numbers of orphans. These visual and practical consequences of HIV may be important in determining how people perceive their own risk of infection, and hence their willingness to undergo VCT.
Countries where HIV-2 is the prominent infection may have high seroprevalence rates but low levels of morbidity, therefore fewer people will be prompted to test for HIV since they see less evidence of vulnerability in their community.