Invitations given by influential people, supported by leaders of respected networks in the community prompted one in five couples, living together or not, to go for joint HIV counselling and testing in two neighbourhoods in Kigali, Rwanda American and Rwandan researchers report in the online edition of AIDS.
The likelihood of testing increased when the invitation was given in the home; by someone known to the couple (aOR = 1.4; 95% CI: 1.2-1.6); preceded by public announcements (aOR = 1.2; 95% CI: 1.1-1.5); as well as the presence of a mobile HIV testing unit (aOR = 1.4; 95% CI: 1.0-2.0).
In Kigali, the capital of Rwanda, HIV prevalence among those aged 15 to 49 is 7.3%, the highest in the country, but rates of HIV testing remain low.
Couples’ HIV voluntary counselling and testing (CVCT) where both sexual partners test together, mutually disclose their results and are counselled accordingly is considered an effective prevention strategy.
In sub-Saharan Africa rates of heterosexual HIV transmission among couples in stable relationships vary from 30% to 70-90%.
In Kigali an estimated 6.2% of couples are in discordant relationships (where one is HIV-positive and the other is HIV-negative).
The Project San Francisco (PSF) begun in 1988 became a couples’ counselling and research centre in Kigali after women attending antenatal care clinics said they would like their husbands to test for HIV. A male-focused intervention was successful in increasing the numbers of male partners tested. The work undertaken by community health workers has strengthened the link individuals have with the healthcare system.
Kristin Wall and colleagues undertook a prospective random cohort study from July 2004 until December 2005 to look at predictive factors for CVCT.
From nine neighbourhoods in Kigali three were chosen based on comparable population size and infrastructure; two of which (with populations of 56,809 and 64,049, respectively) were randomly selected for active CVCT promotion activities together with a stand-alone CVCT centre. At the midpoint of the study a mobile unit crossed over from one neighbourhood to the other. Each centre and mobile unit could see up to 30 couples a day.
The researchers chose to modify a successful pilot study that used Influence Network Agents (INAs) alone. It showed community leaders making public endorsements of CVCT increased couples’ testing.
26 Influence Network Leaders (INL) were recruited who then nominated 118 agents and supported their efforts by publicly endorsing CVCT.
Leaders were recruited through referrals and trained by physicians and counsellors. Candidate agents nominated by leaders were interviewed, selected and trained. Leaders and agents were encouraged to work together. For example a church pastor (INL) would endorse CVCT in a sermon after which deacons (INAs) would give the congregation invitations.
Agents completed data forms every two weeks and were paid $0.30 for each invitation given plus $3 for each couple tested. Couples going for CVCT services were paid transportation costs, given lunch and childcare at the CVCT sites.
Each agent distributed an average of 212 invitations resulting in an average of 38 couples tested for each agent.
Effective outreach workers tend to be from the community they are working in and of comparable age, note the authors. In this study men and women had equal success in promoting CVCT.
Older agents were more successful among couples living together, while younger agents, notably those who were unemployed, did better with couples not living together.
In crude analyses an agent inviting both partners rather than one (of a couple living together) showed a 20% increased likelihood that the couple would go for testing.
Independent factors for increased uptake of CVCT among couples living together included older age of the couples and the longer the time of the relationship.
In couples living together older men were more likely to test, and conversely among those not living together it was younger men.
Couples who knew the INA on a personal or social level were more likely to test. The authors note this supports the concept of “influence network”: knowing and respecting the person delivering the message will have the most success.
In multivariate analysis mobile units predicted CVCT. They are acceptable; and bring services closer to those who need them, overcoming a major barrier to HIV counselling and testing.
The authors note that during the time of the study CVCT was not yet standard practice. However government antenatal clinics encouraged pregnant women to invite their husbands to test. Increases in the proportions of partners tested varied considerably among neighbourhoods.
While the authors thought their intervention may have had a spill-over effect on partner testing in ANC clinics, they note that the clinic seeing the greatest number of male partners was the first in Kigali to start a PMTCT programme.
The authors stress that during this time pregnant women and their partners were not routinely tested together and disclosure was neither sought nor documented.
Their CVCT advocacy had a positive effect on policymakers and donors. However, the Government of Rwanda did not adopt counsellor-training guidelines detailing post-test counselling until 2009.
The authors conclude this “successful model may be replicated and adapted to educate and encourage couples to attend CVCT in other countries…to help reduce HIV transmission in the highest risk-group in sub-Saharan Africa.”
Wall K et al. Influence network agent effectiveness in promoting couples’ HIV counselling and testing in Kigali, Rwanda. Advance online edition AIDS, 25, doi: 10.1097/QAD.0b013e32834dc593, 2011.
