Studies from developing countries

Cd’Ivoire

VCT services are available at several centres in Abidjan and in association with MTCT interventions at ANC clinics.

In an attempt to look at the effect of VCT on behaviour change, 208 seropositive people were interviewed from 7 different AIDS care centres there. Basic knowledge about HIV was good (Doumatey et al., 1998²⁵⁷). Reported sexual behaviour indicated that many people were practising safer sex:

Since testing seropositive

- 42% used condoms always
- 28% used condoms occasionally
- 26% had abstained since receiving a seropositive result
- 50% believed they were “more responsible sexually”
- 12% believed they may have infected their partner, even after testing
- 28% had partners who were not tested

However, there was no pre-test behavioural information, so the impact of VCT on sexual behaviour could not be adequately assessed.

Democratic Republic of Congo (former Zaire)

Limited VCT services were available for antenatal women but were curtailed because of political unrest. (See studies from Kinshasa (Kamenga et al., 1991²⁵⁸ under section 1.1 and Ryder et al., 1991²⁵⁹). Also see study on sex workers (Laga et al., 1994²⁶⁰ under section 1.1).

Ethiopia

Astudy of factory workers in Addis Ababa described their sexual behaviour prior to testing and knowledge about HIV transmission. Overall seropositivity among this group was 12%. As yet there are no data on behaviour change following VCT (Sahlu et al., 1999²⁶¹).

Kenya

VCT services are available at several NGO and government sites and in association with MTCT projects. In a study from Kenya women were offered VCT as part of their antenatal care. Women who tested positive and a comparison group of uninfected women were followed up for one year (Temmerman M, et al., 1990²⁶²). They had each received one session of post-test counselling where HIV, family planning and sexual behaviour were discussed. Family-planning use, condom use and pregnancy rates were similar in both groups. The authors conclude that this single session of counselling was therefore ineffective in this setting, in influencing decisions on subsequent condom use of reproductive behaviour. However, it may be difficult for women to influence safer sex behaviour in their relationships since, in the majority of cases, their sexual partners were unaware of their HIV status. Furthermore, in Kenya, as elsewhere, women often have difficulties in discussing HIV and sexual behaviour and insisting on condom use, especially with their long-term partner.

Rwanda

See under sections on seroincidence Section 1.1, and couple counselling 1.7 (Allen et al., 1992; 1993, Allen, Tice et al., 1992).

See section on partner disclosure, Section 1.6 (Ladner et al., 1995).

Uganda

Uganda has the most developed VCT services in sub-Saharan Africa. Since 1990 VCT has been available through the AIDS information (AIC) in Kampala, where over 380 000 people have been tested (UNAIDS, 1999²⁶³). Further VCT centres have subsequently been established throughout Uganda (Magombe et al., 1998²⁶⁴). There are currently over 20 satellite sites in operation. The AIDS support organization (TASO) is closely associated with AIC and offers ongoing counselling and a wide range of support services for people with HIV.

There have been several studies looking at the effectiveness of the VCT service and the ongoing support services provided by TASO and AIC.

A study of 250 HIV consecutive positive and 250 HIV negative people attending the AIC compared them with 200 consecutive clients who had previously tested negative and were attending for a repeat test (Muller et al., 1992²⁶⁵). The majority of the people attending for repeat testing reported one sexual partner (67%) or sexual abstinence (25%). When compared with pre-test information from people attending the AIC for their first test, repeat testers were significantly less likely to report having casual sex (6% versus 25%). Repeat testers were also more likely to use condoms with casual sexual partners. Of the 200 repeat testers only 2 (1%) had seroconverted. It should be noted, however, that the “repeat testers” might differ from the “first-time testers”.

An uncontrolled study of reported behaviour change at the AIC has shown significant changes in sexual behaviour following VCT (Moore et al., 1993²⁶⁶). Reported condom use rose from 10% to 89% with steady partners, and from 28% to 100% with non-steady partners of HIV seropositive clients. This study relied on reporting of sexual behaviour on a checklist questionnaire.

Aquantitative and qualitative study from the TASO counselling service shows a good understanding of safer sex and a high level of safer sex behaviour following VCT(Kaleeba et al. 1997²⁶⁷, and TASO, 1999²⁶⁸). When seropositive people in the TASO evaluation reported current sexual practices, 45% (56% females and 28% males) said they were abstinent and 33% (26% females and 48% males) said they used condoms. Of those who said they were using condoms 81.3% said that they had done so after seeing the counsellors at TASO. Fifty-seven per cent of those who said that they were using condoms said that they were using them consistently, and seventy-four per cent said that they had used them in their last sexual encounter. The reported condom use was higher than that reported in the general population, where 10% of people said that they had “ever used” condoms (Konde-Lule & Sebina 1993²⁶⁹). In the most recent evaluation of TASO 12 120 records of clients attending between 1997-1999 were examined (Mukasa-Monico et al., 2000²⁷⁰). Condom use increased from 23% to 41% for women and 20% to 49% for men following VCT. Further increases in condom use were seen in people who had further post-test counselling sessions.

VCT in rural Uganda has also been evaluated. A small, uncontrolled study from rural Uganda reports condom use in 50% of people following VCT (Kamaya, 1998²⁷¹).

In a rural community cohort from Rakai VCT was promoted and provided free of charge (Lutalo et al., 2000²⁷², Nyblade et al., 2000²⁷³). Behaviour change in the 20 months following VCT was examined in four groups: seropositive people who received VCT (N=370), seronegative people who received VCT (N=2304), seropositive (N=562) and seronegative (N=2860) who did not receive VCT. For all groups there was not a statistically significant difference in most risk behaviours between those who had participated in VCT and those who had not. However, for both seropositive men and women who reported no condom use at the first survey, those who received VCT were more likely to report condom use at after 20 months compared with non-VCT recipients (23.5% versus 12.8% for men, 15.5% versus 7.6% for women p=0.05 for both). Furthermore, women who were seropositive and had received VCT had higher rates of condom use than seronegative women who received VCT (12.3% versus 8.3%). Among males condom use was moderately higher (but not significantly different) among seropositives than seronegatives following VCT (23.6% versus 19.0%). However, it may be more appropriate to compare both seropositive and seronegative with unaware controls as the aim of VCT is to promote condom use for all clients unless seronegative people are in a mutually faithful relationship with someone who had been tested negative.

Zambia

VCT services have been available in Lusaka since 1992, when Kara Counselling and Training Trust developed them in conjunction with support services for PLHA. Several studies from Kara have looked at sexual behaviour, emotional and social outcomes and coping following testing. Other counselling projects have been developed associated with hospitals or home-based care programmes (Jordan, 1995²⁷⁴). In 1999, a countrywide VCT service was started and is being introduced throughout Zambia (Ministry of Heath interim report, 2000). Following successful pilot projects of VCT associated with MTCT interventions, this service is also being expanded (see Chibwesha et al., in section 7 operational aspects of VCT).

Studies from the Kara Counselling service in Zambia have demonstrated some changes in sexual behaviour following VCT (Kelly et al., 1994²⁷⁵, Baggaley et al., 1998²⁷⁶,²⁷⁷). Following VCT both those testing seropositive and seronegative were more likely to use condoms and reduced their number of causal sexual partners, when compared with reported behaviour prior to testing. However, in other studies from Kara, some women expressed difficulties about using safer sex methods because of poor communication with their sexual partner/s (Chanda et al., 1994²⁷⁸).

Also see under seroincidence/seroconversion Section 1.1 (Hira, 1990).

Zimbabwe

VCT services in Zimbabwe were not widely available until recently. Social marketing of VCT through The “New Start” project commenced in 1999, which to date has nine operational VCT centres, with others planned (PSI 1999²⁷⁹, Moses et al., 2000²⁸⁰, Sangiwaet al., 2000²⁸¹). An evaluation of these sites is currently taking place. These have been popular with both singles and couples. To date, 7000 people have attended the sites, with 10% being couples. There have been no data presented (to date) on the social and behav-ioural consequences of testing. VCT services in Bulawayo have been studied (see Meursing et al., 1993/1995/1999 in Section 3.2 on access to ongoing emotional/psychological care).

The multi-centre trial: the United Republic of Tanzania, Kenya, Trinidad and Tobago

Recent results from the CAPS/AIDSCAP/WHO/UNAIDS multi-centre trial have given encouraging results (Coates et al., 1998²⁸², 1998²⁸³; Sangiwa et al., 1998²⁸⁴; 2000²⁸⁵; Kamenga et al., 2000²⁸⁶; Balmer et al., 2000²⁸⁷; Furlonge et al., 2000²⁸⁸, The VCT efficacy study group 2000²⁸⁹). This study was the first randomized trial of HIV counselling and testing from developing countries. Participants were randomized to receive either health information or VCT. The study was designed to compare the prevalence of self-reported, unprotected intercourse at six months follow-up between the groups. Information on the social and psychological consequences of receiving VCT was also collected, and a cost-effective analysis performed.

The results of the study (N=3 120, 1 534 males and 1 586 females) showed that percentage of individuals reporting unprotected intercourse with non-primary partners declined significantly, more for those receiving VCT than for those receiving health information (HI) only. (Males: 35% reduction in VCT group versus 13% in HI group; females: 39% reduction in VCT group versus 17% reduction in HI group).

Similar differences were observed in the number of unprotected episodes with non-primary partners (males: 37% in VCT group versus 12% reduction in HI group; females: 42% in VCT groups 12% reduction in HI group). Among those assigned to VCT at baseline, those diagnosed with HIV were more likely to change their sexual behaviour than those diagnosed as HIV negative.

The rate of incident STIs among men assigned to VCT was 46% less than those assigned to HI only (3.5% versus 1.9% p= p 0.1), but rates among women were almost the same (6.2% versus5.6%). Self-reports of unprotected sexual intercourse between baseline and first follow-up were strongly associated with incidents STIs at the first follow-up.

In couples (N=586), 74% were seroconcordant negative, 9% seroconcordant positive, and 17% were serodiscordant (6% were M+ F- and 11% were M- F+). At the first follow-up, both VCT and HI couples (in which one or both were seropositive) decreased significantly in the rate of unprotected intercourse with their study enrolment partners relative to couples in which both were negative.

Furthermore, VCT couples were significantly more likely to report reduced unprotected intercourse with their spouse than HI couples, but there was little change in reported sexual behaviour with secondary sexual partners.

This study, therefore, supports the efficacy of VCT in preventing HIV transmission in serodiscordant couples. Previous research in Africa and the United States has also suggested that VCT is more effective for HIV risk reduction when both partners participate in the process together, share their test results and formulate risk reduction plans based on their HIV test results.

India

The HIV incidence and prevalence is rapidly rising in India. The predominant mode of transmission has been through heterosexual contact between female sex workers and their clients. However, there is increasing seroprevalence among married monogamous women whose only risk factor was sexual contact with a husband who also has had an STI. In north-east India the number of cases of HIV infection is increasing due to IDUs. It has been estimated that by the end of 1999 there were 4 million people living with HIV in India.

Efforts to provide VCT started in India in 1987. By 1992, there was a national training programme for counsellors. There are six regional VCT centres. However, private medical practitioners, some of whom do not offer adequate counselling or ensure informed consent prior to testing, carry out much of the HIV testing. Anonymous VCT services are also being developed (Bhandariet al., 1998²⁹⁰). NGO services are popular and some report increased condom use following VCT (Kalyanasundaram, 1998²⁹¹).

In a study from Pune the role of VCT in HIV prevention among those who test negative was examined (Bentley et al., 1998²⁹²). There were 1 628 seronegative heterosexual men recruited from a STI clinic. They were seen every three months for repeat VCT for twenty-four months. Counselling was focused on reinforcing messages of monogamy, condom use with sexual partners and provision of condoms. This ongoing counselling and testing was positively associated with risk reduction behaviours. At six months men were 2.8 times - and at twenty-four months 4.7 times - more likely to consistently use condoms with sex workers.

Thailand

In Thailand the first cases of HIV were seen in 1984 and 1985 among IDUs. The epidemic rapidly became more widespread with increasing seroprevalence seen among female sex workers, males attending STI clinics and women attending antenatal clinics. By 1993, 600 000 to -800 000 people were estimated to be infected. The Thai Red Cross quickly established a network of VCT services. VCT services are also widely available in many government institutions (Guntamala et al., 1998²⁹³) and are now provided in some provinces associated with MTCT interventions.

In 1993, consecutive samples of 250 seropositive and seronegative patients were recruited to evaluate the effectiveness of VCT in promoting behaviour change (Phanuphak et al., 1994²⁹⁴). Following VCT most clients expressed the intention to reduce HIV risk behaviour in response to a positive or negative HIV test result (more so if seropositive). This study relies on intention to reduce HIV risk behaviour and although the results are encouraging they cannot be verified.

A study from Bangkok compared self-reported behaviour of seropositive people who had received VCT with those from a matched sample of seropositive people who were unaware of their status (Muller et al., 1995²⁹⁵). Of the people who had received VCT 84% reported that they had decreased their number of sexual partners since receiving it. They also reported more frequent condom use than did seropositive people who were unaware of their status.

Myanmar

There are estimated to be over 400 000 cases of HIV infection in Myanmar. VCT services have been added to 28 pre-existing health services in townships through out Myanmar (see Kywe et al., 1996²⁹⁶ and Thu 1997²⁹⁷ under section 7 on the operational aspects of VCT).

Latin America and the Caribbean

VCT services have been developed in many countries in Latin America and the Caribbean. In Chile the NGO FRENASIDA (Chilean Association to prevent AIDS) has operated a VCT centre in association with the Government since 1991. The prevalence of HIV remains relatively low (in Santiago the estimated sero-prevalence is 25.6 per 100 000 Caceres et al., 1996²⁹⁸ & UNAIDS 1999²⁹⁹). They report a relatively low uptake and low return for HIV testing but among those who do test almost 70% report having modified their behaviour in some way, including increased frequency of condom use (Gonzalez et al., 1997³⁰⁰).

In Brazil, currently all but two states there offer VCT services that are confidential and free of charge. Counselling services have been available since 1988, but the quality and uptake of these services varies considerably. Strategies to evaluate implementation of HIV prevention strategies by VCT sites have been developed (Passarelli et al., 2000³⁰¹). During 1997, ten public health services were visited. Although VCT coun-sellors were able to offer care and support for PLHAthey were found not to be effective in helping PLHAto overcome their difficulties in adopting safer sex practices (Filgueiras et al., 2000³⁰²).

It is estimated that there are some 18 000 people with HIV in Jamaica. The counselling and community outreach programme (CCO) has been developed to offer psychosocial support for people with HIV.

Studies from industrialized countries

Students

A randomized-controlled trial of VCT versus HIV education alone was carried out among students (Wenger et al., 1992³⁰³). When interviewed at six months follow-up, the students in the VCT group had increased communication with sexual partners about the risk of HIV infection. However, no consistent differences among the groups in the number of sexual partners or the use of condoms were found at follow-up.

STI clinic attendees

In another study carried out by the same group in Los Angeles the effect of VCT versus AIDS education was looked at among consecutive attendees at an STI clinic (Wengeret al., 1991³⁰⁴). At follow-up the mean number of sexual partners decreased, but there was no significant difference between the groups. However, the VCT group questioned their most recent sexual partner/s more about HIV (p=0.01), “worried more about getting AIDS” (P=0.03), and tended to use condoms more often with their last sexual partner (p=0.05). Of VCT subjects, 40% versus 20% of the information group used condoms, avoided genital intercourse, or knew that their last sexual partner had a negative antibody test (p=0.005).

Women clinic attendees

A study of women attending family planning and gynaecology outpatients revealed that being tested for HIV did not result in any significant changes in condom use, self-reports of STIs or number of sexual partners in the four months following testing (Wilson et al., 1996³⁰⁵).

Another study from the United States compared the effects of VCT on sexual behaviour among women attending four primary health care clinics (Icovics et al., 1994³⁰⁶). One hundred and fifty-two seronegative women and seventy-eight women who had never been tested (matched for age and race) were questioned about their sexual behaviour at two weeks and three months after the VCT baseline. There were no significant differences in the groups and no significant changes in risk behaviour in either group. The authors suggest that women who seek VCT may have already made changes in their sexual behaviour prior to requesting VCT.

VCT sites

A study assessing the free, anonymous, public VCT service at two sites in North Carolina, had disappointing results (Landis et al., 1992³⁰⁷). No significant changes were found in high-risk sexual behaviour at follow-up.

Serodiscordant couples

See under section 1 (Padian et al., 1987).

In these studies the prevalence of HIV was relatively low. There were no people with seropositive results who took part in the intervention groups in the studies by Wengeret al. In the study by Icovicset al., women were recruited from clinics in southern Connecticut, where there is little morbidity or mortality from HIV outside higher risk groups. This may mean that while women are willing to undergo testing they do not perceive themselves to be at significant risk from HIV and therefore do not feel it is necessary to make changes in their sexual behaviour. This emphasizes the difficulties in making comparisons between studies from low-prevalence industrialized countries and much higher-prevalence developing countries.

Studies among MSM

Comparisons between groups before and after testing available

Some studies of sexual behaviour in MSM started before HIV testing was available, allowing comparisons of sexual behaviour before and after VCT was established.

A study from the United States followed a cohort of homosexual men from 1984, before HIV testing was available, until 1986 when HIV testing was available (Coates et al., 1987³⁰⁸). Men who were aware of their HIV status were significantly less likely to practise unsafe sex (12% of seropositive men, 18% of seronega-tive men and 27% of untested men practised unsafe sex). All groups had, however, started to change their sexual behaviour before HIV testing became available. All reported significantly higher rates of unprotected sexual intercourse before HIV testing was available (48% who ultimately tested positive, 49% who did not test and 41% who ultimately tested negative).

A study from the Netherlands also showed that MSM had started to change their sexual behaviour prior to VCT being made available (van Griensven et al., 1989³⁰⁹). They also showed that seropositive MSM were more likely to use condom during anal intercourse (with both steady and casual partners) than were seroneg-ative and untested MSM.

Inconclusive studies

Several studies suggested that although there were considerable reductions in risky sexual behaviour over time these were not clearly associated with VCT.

A study from Canada followed a cohort of homosexual men from 1984-1987 (Schechter et al., 1988³¹⁰). Following VCT, the annual number of sexual partners fell for both those with seropositive and seronegative test results and there was a marked increase in condom use. More seronegatives than seropositives reported no condom used during anal intercourse with regular partners (45.7% versus 23.4%) and with casual partners (15.9% versus 1.5%). (There was, however, no control group of untested). Asmall group of people who had the largest number of casual sexual partners was also the most likely not to be using condoms with these partners. Although marked risk reduction was noted for MSM who were aware of their HIV status, a few men continued to put themselves at extremely high risk.

A study from Chicago showed that all MSM decreased risky sexual behaviour but there was no significant difference between men who were aware of their HIV status and those who were not (Ostrow et al., 1989³¹¹).

A study from the United States compared MSE who were aware of their HIV status, with men who had been tested but declined to receive their test result (Doll et al., 1990³¹²). Both groups had access to risk-reduction information. In both groups there was a significant decline in unsafe sexual behaviour, but these declines were independent of knowledge of HIV status and actual serostatus.

In a longitudinal study of 139 MSM from Boston, all groups (seropositive, seronegative and untested) showed a decline in risky sexual behaviour, but there was no difference between the groups (Zapa et al., 1991³¹³).

Twenty-two seropositive MSM, twenty-two seronegative MSM and twelve men who were tested (but did not want to know their HIV status) were surveyed one week and six months after testing (Huggins et al., 1991314). All three groups altered their sexual behaviour, with no significant difference between the groups.

A study from four cities in the United Kingdom also showed no evidence for decreasing risky sexual behav-iour following VCT (Dawson et al., 1991³¹⁵).

In a study from 16 small cities in the United States there were mixed findings (Roffman et al., 1995³¹⁶). Although MSM who had undergone VCT reported more condom use and had more protected penetrative sexual acts than untested MSM, they also had a significantly greater number of sexual partners. Therefore, overall untested and tested MSM reported a similar number of unprotected sexual acts.

Declines in risky sexual behaviour, associated with VCT

Several early studies do, however, show significant decreases in risk behaviour associated with VCT, with seropositive men showing greater reduction in risk behaviour than seronegative men or men who are unaware of their HIV status. It is suggested that learning about being seropositive had a greater impact on changing behaviour and showed that seronegative men were still putting themselves at risk from infection.

In a study from Baltimore, United States 1 001 MSM were offered VCT (Fox et al., 1987³¹⁷). Of those, 670 elected to have VCT and 311 declined (the two groups had similar baseline characteristics). All were coun-selled about safer sex. In all groups unsafe sexual practices declined, although disclosure of a seronegative test result led to a significantly smaller decline in these sexual activities

In Boston, MSM who tested seropositive were more likely to have protective sexual behaviour than seoneg-ative or untested men (McCusker et al., 1988³¹⁸)

Three cohort studies (Cohn et al., 1988³¹⁹, Zones et al., 1986³²⁰, McKusick et al., 1990³²¹) and three cross-sectional studies also showed an association between VCT and reduction in risky sexual behaviour (Valdiserri et al., 1988³²², Frazer et al., 1988³²³, Ross 1988³²⁴).

Long-term studies, however, have shown that initial changes in sexual behaviour following VCT may be difficult to maintain. In a study from the United States, at two years 47% of people had “relapsed” (not used safer sex practices) at least once (Abid et al., 1991³²⁵).

Studies among IDUs

Harm reduction/safe injecting

Significant change in injecting practices attributable to VCT

Some studies have found increases in safe injecting practices following VCT.

· In a study of 933 IDUs attending a detoxification centre in Milan (Nicolosi et al., 1991³²⁶) a preventive intervention based on VCT was associated with a significant reduction in sharing of syringes and unsafe injecting practices compared with risk behaviour in IDUs who had not received the intervention. The latter group showed no change - or even an increase, despite general information and HIV health education campaigns.

· In a small study of IDUs attending a detoxification programme in Long Island, United States both seropositives and seronegatives had reduced risk behaviour (Magura et al., 1990³²⁷). There was, however, no untested control group for comparison.

· In a study from New York City, seronegative IDUs attending a methadone maintenance treatment pro-gramme were less likely to use unsafe injecting compared with seropositive or untested IDUs (Magura et al., 1991³²⁸).

· In a study from 12 European countries, seronegative compared seropositive, seronegative IDUs and IDUs who had not received VCT (Desenclos et al., 1993³²⁹). Seronegative IDUs reported higher rates of safe injecting compared with untested IDUs. Seropositive IDUs were also less likely to give their injecting equipment to other IDUs compared to IDUs who had not received VCT.

· In a study of 5 644 attendees at needle exchange programmes and detoxification centres in California, the factor most closely associated with not sharing syringes was having attended VCT (Watters et al., 1994³³⁰).

· Studies from Australia have shown the benefits of needle-exchange programmes (NEPs), methadone replacement and VCT services, resulting in low HIV prevalence rates among IDUs in Australia. However, it is difficult to attribute one intervention to this success (Drucker et al., 1998³³¹).

· VCT and NEPs have expanded substantially in New York. The percentage of IDUs using NEPs has risen from 20-54% and those using VCT from 51-81% during 1990-1997 (Des Jarlaiset al., 2000³³²). Ameta-analysis of studies among over 11 000 IDUs from New York during 1990-1997 has shown that knowledge of HIV status and attendance at NEPs were associated with less risk behaviour. Using a NEP had an OR=0.64 (p=<0.001) for sharing at last injection and knowledge of a seropositive status had an OR=0.35 (p=<0.001) for unsafe sex with primary sexual partner. During this time the HIV incidence fell from 4.4 per 100 person-years to 0.8 per 100 person-years for those at risk. The authors conclude that while there are multiple causes in the process of declining HIV incidence among IDUs in New York there is a clear pattern of increased use of NEPs and VCT which were temporally associated with a large reduction in HIV incidence.

No significant change in injecting practices attributable to VCT

· In a study from New York (associated with a methadone maintenance programme) most people testing seronegative and seropositive stopped injecting drugs. Those who continued to inject were more likely to use safe injecting practices, but there was no significant difference between those who were aware of their status and those who were not (Casadonte et al., 1990³³³).

· In a study from Washington, United States, 313 IDUs were randomly assigned to HIV education, HIV education plus VCT or a waiting list (Calsynet al., 1992³³⁴). The sample as a whole decreases high-risk behaviour but there were no significant differences between the groups.

· In a study from Puerto Rico, VCT was offered to IDUs recruited from a street-selling area (Conlon et al., 1996³³⁵). Of the 374 participants 88% agreed to be tested and returned for their results and 73.5% were followed up and interviewed six months later. Of the 176 IDUs who reported a seronegative test result prior to base line, 26% were subsequently found to be seropositive. No significant difference was found between seropositive and seronegative IDU risk behaviour.

· In a study from central Massachusetts, 4 267 individuals were provided with VCT at a multi-site programme, including community clinics, drug treatment programmes and prisons. Half of those tested reported risk behaviour associated with IDU. Asample of 207 IDUs were followed up following VCT (McCuskeret al., 1996³³⁶.). Among those who continued to inject drugs there was a reduction in the percentage visiting shooting galleries following VCT but no other significant behaviour changes were reported.

· In a multi-centre study from the United States, 1 174 seronegative IDUs who were in drug treatment programmes were questioned about their injecting practices following VCT (Sabin et al., 2000³³⁷). VCT did not alter risk behaviour in these programmes.

· In a study of male IDUs attending drug treatment centres in Northern Thailand there was no difference in changing risk behaviours among those who had prior VCT and those who had not (Kawichai et al., 2000³³⁸). The authors conclude that HIV prevention programmes, including VCT, have been extensively introduced over the past decade in Thailand and have reduced the incidence of HIV. Ageneral trend in reducing risk behaviours in Thais might have been the reason for not observing significant change in IDUs following VCT.

· One study has examined whether VCT increases the likelihood of IDUs adhering to a drug treatment programme (MacGowan et al., 1996³³⁹). Knowledge of HIV status did not affect retention.

Sexual behaviour

Significant change in sexual behaviour practices attributable to VCT

The majority of studies show a reduction in risky sexual behaviour of IDUs following VCT.

· In a study from 12 European countries seropositive IDUs reported higher rates of condom use compared with seronegative and untested IDUs. (Desenclos et al., 1993).

· In a study from New York City, seropositive IDUs attending a methadone maintenance treatment pro-gramme were more likely to use condoms compared with seronegative or untested IDUs (Maguraet al., 1991).

· A study from Bangkok and New York City showed that seropositive IDUs were more likely to practise safer sex than seronegative or untested IDUs (Vanichseni et al., 1992³⁴⁰, 1993³⁴¹).

· In a study from Puerto Rico, following VCT, seropositive IDUs were less likely to report being sexually active and more likely to use condoms, than untested or seronegative IDUs (Colon et al., 1996).

· A study from New York found that seronegative IDUs who had received VCT were more likely to always use condoms than seronegatives who had not received VCT (Friedman et al., 1994³⁴²). However, this difference was not seen among seropositive who received VCT compared with seropositive who were unaware of their status. The authors attributed the similarity in condom use between tested and untested seropositive IDUs to changes in condom use made by IDUs who suspected that they were HIV infected and had thus made changes in their sexual behaviour based on this assumption.

These findings suggest that community interventions aimed at providing VCT - and thus detecting seropos-itive IDUs, counselling them about their status and assisting them to reduce the risk of transmitting HIV - are effective in reducing the spread of HIV from IDUs to their sexual partner/s.

In most studies, changes in behaviour to prevent sexual transmission of HIV are more marked among those who test seropositive than among those who test seronegative. This indicates that seronegative IDUs may be continuing to put themselves at risk from sexual transmission of HIV (particularly if their sexual partner is also an IDU). Emphasis on providing counselling about prevention of sexual transmission of HIV for IDUs who test negative is important.

No significant change in sexual behaviour attributable to VCT

Three VCT interventions for IDUs have not resulted in any significant changes in sexual behaviour that could be directly attributed to VCT (Nicolosi et al., 1991, McCusker et al., 1996, Calsyn et al., 1992).