In 2009, 22.5 million people in this region were living with HIV, and an estimated 1.8 million people were newly infected in this region (UNAIDS, 2010). Respectively, this accounted for 67 and 69 percent of persons living with HIV/AIDS (PLHA) and new infections worldwide in 2009. In the same year, deaths due to HIV in sub-saharan Africa amounted to 1.3 million. (UNAIDS, 2010)
Lack of knowledge of disease status is a major obstacle to reducing high incidence and burden. Though HIV counseling and testing effectively reduces new incidence of HIV, low participation in voluntary counseling and testing programs remains a serious challenge. Surveys conducted in 12 high burden countries in sub-saharan Africa found that only 12% of men and 10% of women in the general population had been tested and received their results (WHO, 2007). Futhermore, the highest incidence rates of HIV in this region occur among married and cohabitating couples (Allen, 2005; Dillnessa, 2010). As such, increasing counseling and testing among this population is paramount to reducing the HIV epidemic, but has proved challenging.
Couple Voluntary Counseling and Testing
Voluntary counseling and testing (VCT) is a process in which an individual or couple receives counseling and then makes a decision whether or not to be tested for HIV. The individual or couple must be assured that the process is confidential (Reynolds & Morgan, 2002).
The goals of VCT are to prevent HIV transmission from positive people to negative partners and untested partners; prevent HIV acquisition among HIV negative persons from positive or untested partners; increase uptake of early care and treatment for positive people; emotional care and risk reduction strategies for negative tested people, family planning to prevent mother to child transmission, counseling for adherence to treatment therapy and other prevention interventions. VCT services also strive to normalize HIV, reduce stigma and discrimination, promote awareness and support human rights.
Couples represent the highest risk group for HIV in Africa and studies indicate that only 1% of couples are tested in the region (Dillnessa, 2010). With HIV in sub-saharan Africa being transmitted mostly through heterosexual relations, the need for VCT for couples is increasingly important to help couples plan, make important life decisions, and to seek care and support together. Couple VCT should also be promoted and expanded within a human rights framework because of the high frequency of serodiscordancy and the important potential to reduce transmission in serodiscordant couples (World Health Organization, 2007).
Most literature addressing voluntary testing and counseling in Sub Saharan Africa focus on the individual and not couples and is limited to a few countries leading the CVCT programming such as Zambia, Rwanda, and Uganda. Even in these countries, limited data is available. However, that data does illuminate the challenges and obstacles in the uptake and acceptability of CVCT.
Uptake of CVCT:
The literature substantiates the efficacy of CVCT as an effective intervention strategy in preventing transmission of HIV in couples and in Prevention of Mother to Child transmission (PMTCT) in Sub-Saharan, Africa (Painter, T. 2001).
Studies show varied outcomes from CVCT programs. For example, a study in Lusaka, Zambia showed that when CVCT was given as part of VCT services, couples were reluctant to test together because it was not popular to do so (Baggaley et al., 1997). In contrast, a study conducted with couples in Rwanda as part of a research study for discordant couples found that it was a popular option to participate. None of the couples declined the testing and counseling nor declined to have the investigators to give their test result to their partner (King et. al., 1993).
A 2008 study in Zambia on the Evolution of Couples Voluntary Counseling found that when CVCT was promoted as part of promotional strategy, the demand for CVCT increased. Promotion activities included media advertising via radio, newspaper advertisements in 3 city papers and Community Outreach Workers (CW) going door to door in neighborhoods near the clinic However, when promotion outreach activities ended, the request and attendance dropped off from 309 couples per month in 1996 to 20 couples per month in 2000.(Chomba, E., Allen, S., et al., 2008).
Another study conducted in Uganda found that the reason men didn’t test as part of PMTCT was due to mistrust in their marriages, lack of experiencing symptoms, and perception of some of the health care providers at the antenatal clinics having rude attitudes causing the men to feel unwelcomed (Larrson, E., Thorson, A., et al., 2010). Two studies conducted in Ethiopia found a 14.5 % uptake of CVCT in two PMTCT studies located in hospitals and a health center.
HIV Stigma and Discrimination
Stigma and discrimination in various communities has been shown to affect the uptake of CVCT. In Uganda, the government commitment to HIV prevention and care has lessened the discrimination and increased the demand for HIV testing. When famous people or respected people in the community, in the country or world test and learn their status, the demand for VCT rises. Senator Obama and wife Michelle tested in a village in Kenya in 2006 to show the importance of testing and knowing your status so that you could be referred for treatment if found sero-positive and counseled on risk reduction behaviors if sero-negative or sero-discordant. In Ethiopia, a 2004 study was conducted to understand the main causes of stigma, manifestations, consequences, and coping mechanisms. This qualitative study found that the source of HIV and AIDS information was obtained in community meetings, friends, family members, and community associations like Ider (association that takes care of funeral expenses). The interviews revealed that there was an attitude of fear, hate, shame, blame and disgrace in the study population. Rumors and mis-information, and judgment were on People living with AIDS (PLHA). Lack of knowledge and mis-information about transmission, prevention and care prevailed and lead to stigma and discrimination of PLHA (The Miz-Hasab Research Ctr., 2004).
In Rwanda, a study was conducted to assess couples knowledge of VCT, willingness and obstacles to get tested revealed that 90% knew where to get tested, 93% knew about CVCT, and greater than 95% approved of testing with partner. Influence Network Agents postulated that the main obstacle would be cost and time to go get tested. The results showed that 41% of respondents feared his/her partner, 29.9% had a fear of stigma, and 14.1% stated finances as the main impediments of not getting tested.
Studies have shown that many couples have serodiscordant HIV results. A 2004 study in Uganda revealed that HIV infected women within HIV discordant couples are more likely to be divorced or separated than women within other HIV status couples.
Socioeconomic Factors and CVCT
According to a study by Helleringer, Kohler, & Frimpong, (2011), VCT for HIV is lower among individuals from poor households in sub-Saharan Africa. As a result, there is a significant inequality in the access to VCT for HIV and ARV treatment. The authors note that VCT for HIV in home-based campaigns had a higher uptake in their study among poor households because it reduced the existing socioeconomic challenges that were previously a hindrance. Among the households studied, the authors identified poor accessibility of health facilities as one of the main barriers. They note that although hospitals provide routine VCT for their attendees, the accessibility of healthcare facilities by the poorest individuals was a challenge due to their socioeconomic status. Moreover, other initiatives targeting workplaces also missed the poorest that were less represented in the workplaces (Corbett, et al., 2006). The poverty status of couples also influences the probability of women depending on their husband’s approval to attend VCT services. In most cases, women were unemployed and responded in the study that they relied on the approval of their husbands who provide money for transport to health facilities.
Arthur et al. (2007) explored the behavior change of clients to VCT health centers. They report that social desirability is a major factor affecting the reporting of risky behavior among couples and during VCT sessions. The authors note that couple counseling may be a viable intervention in seeking disclosure among for HIV positive clients of VCT centers.
Thior et al. (2006) looked at socio-demographic predictors of acceptance of VCT among post-partum women in Botswana. They note that acceptance for VCT dropped significantly as age of respondents increased. They attribute the cause of the drop to desire for protection from public shame. In addition, HIV is the leading cause for adult deaths and therefore older women are against testing for fear of getting HIV positive results. Married women had a less likelihood of accepting VCT because of the African setting where they are viewed by society to be under the authority of their husbands. Other than age and marital status, education level of the women under the study was also a major factor. Educated women were less positive about accepting VCT because they were knowledgeable of the risks of status loss due to a HIV positive result.
The HIV epidemic in sub-saharan Africa is complicated by poor uptake of couples’ counseling and testing. Factors influencing poor uptake include stigma, income, lack of access and acceptability. Further research is needed to identify key factors to increase participation in CVC T specific to each health care setting.