Voluntary mass HIV testing as a route to behaviour change

Just as the Uganda Blood Transfusion Service has been a pioneering project in the area of safe blood for developing countries, so too the Uganda AIDS Information Centre (AIC) has been a pioneering experiment in the use of mass voluntary HIV testing and counselling as a contribution to AIDS control, and as a way of encouraging behaviour change in face of the HIV epidemic.

Funded by USAID (United States Agency for International Development), the AIC was the first such project in sub-Saharan Africa. There are now other similar projects in Africa (e.g. Zambia, Cote d'Ivoire), and a multi-country study is under way to determine whether or not such information and testing centres should become an officially recommended part of AIDS control strategy.

Since it began in 1990, the AIC has provided HIV tests with pre- and post-test counselling for about 200,000 people, initially in Kampala only, but more recently through 20 or more regional and local centres as well. The tests are entirely anonymous, based on each person being given a number rather than being asked their name, and about half those coming to the AIC are men, and half women.

The aim has been to replace the negative feelings of hopelessness and fatalism that used to be brought on by the terrifying HIV/AIDS figures in Uganda, by a positive awareness that through knowledge and informed behaviour much can be done to protect those as yet uninfected, not least the partners of infected people. Pre-marital testing, often at the behest of family, priests or clergymen, was another area of unmet demand. The significance of the AIC and its activities for the Uganda Blood Transfusion Service is two-fold:

1. some people were coming to the blood bank offering to donate blood, and so receiving a free blood test, but with no intention of actually becoming a blood donor. Their sole purpose was to get an HIV test, and to get it for free. This was wasting a lot of time and resources at the Nakasero testing laboratory, which anyway did not have the means to do AIDS counselling. So now such people have another place to go to.

2. the HIV testing of the blood samples taken at the AIC is done for the AIC by the Nakasero laboratory on a contract basis, and the UBTS gets paid for each test done, at the rate of over US$ 5 per test. This has been a valuable source of extra funding for the UBTS, and has enabled the UBTS to achieve a degree of self-financing and to pay extra salary money to key employees.

Besides the money, the USAID/AIC business has provided an important 'seal of approval' to the Nakasero laboratory. The AIC could hardly send its blood samples to a laboratory in which it did not have total confidence, especially given the highly sensitive nature of the tests done, determining whether or not a person has HIV/AIDS. The high rate of auto accidents in Uganda also meant that expatriates and visitors to the country were very concerned about the safety of the blood supply. So recognising its 'strong ethical burden to ensure the accuracy of the test results, 'USAID used consultants to carry out its own independent evaluation of the Nakasero laboratory and now calls it 'a remarkable institution... one of the best laboratories in Africa.'

People wanting an HIV test for job or visa applications have to go elsewhere. The AIC does not provide bits of paper stating that the person is HIV-negative. What it does do, is to refer HIV-positive people to TASO, the very active Ugandan AIDS support organisation, and/or to the Post-Test Clubs which the AIC has set up to enable clients, particularly but not only those who are HIV-positive, to get long-term support and advice. USAID recognises that without an adequate support system for those found to be HIV-positive (which not all countries have) mass HIV testing could have a devastating and negative effect, and would also raise serious moral and ethical issues. Taking into account all aspects, including this pre-and post-test counselling, it costs USAID about US$ 18-20 for every person tested at the AIC.