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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
· Content and
quality of counselling
· Number of
counselling sessions undertaken
· Individual,
couple or group pre-test counselling
· HIV
testing methods employed in VCT sites (same-day simple/rapid testing versus
ELISA)
· Associated support services
available to VCT sites
· Anonymous versus
confidential versus mandatory testing and reporting of results
· Age/emotional maturity of clients
· Socio-economic factors (may affect access to
treatment, prophylaxis)
- 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 VCT’s 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. | 
