Voluntary counselling and testing for couples: successes in Zambia

A voluntary counselling and testing programme specifically aimed at couples was widely used when actively promoted in Lusaka, Zambia, according to a paper published in the January 1^st issue of the Journal of Acquired Immune Deficiency Syndromes. Over a six-year period, 8500 married or cohabiting couples were tested for HIV through the programme, of whom 23% were found to be serodiscordant. The authors believe that, as part of African HIV prevention efforts, couples should be widely encouraged to participate in couples' voluntary testing and counselling (CVCT).

Individual voluntary counselling and testing (VCT) is the prevailing strategy for HIV prevention in Africa. However, VCT aimed at couples (CVCT) offers many advantages.

Serodiscordant couples have been identified as a distinct and significant risk group for new HIV infections. Previous research has shown that VCT can reduce HIV transmission, that both partners are much more likely to be tested when CVCT is offered, and that couples may be better able to adapt to preventative behaviour changes when both partners are involved in the counselling.

The Zambia-Emory HIV Research Project (ZEHRP) was established to promote CVCT to couples in a densely populated area of Zambia's capital city, Lusaka. Publicity and promotional strategies were evolved and deployed between August 1994 and August 1998; these included radio and newspaper campaigns, door-to-door outreach, and publicity through large employers and non-governmental organizations (NGOs) in the area.

Couples accessing the program received pretest counselling in the form of a group video presentation and discussion. Couples then spoke privately with a counsellor and decided whether to undergo testing. Those who gave informed consent then received HIV and syphilis serologic testing and post-test counselling. Individual counselling was available on request, although not routinely offered. HIV serology was done by ELISA antibody testing until June 1995, when rapid testing was initiated. Post-test counselling occurred on the day of the rapid test and two weeks after ELISA testing, on receipt of results.

A total of 8500 cohabiting couples sought HIV testing through the ZEHRP program between August 1994 and March 2000. In the first ten months, when promotion was solely through mass media and visits to NGOs, an average of 76 couples per month were tested. In the latter half of 1995, after rapid testing and door-to-door promotion were instituted, uptake increased to 230 couples per month, and reached 309 couples per month during 1996. As the program scaled back from six to three days per week of operation, and active community promotion activities were reduced, uptake declined to 152 couples per month by the end of 1997 and only 33 per month by the end of 1998.

Another goal of the study was to identify demographic characteristics of serodiscordant couples. Several risk factors for seropositivity of at least one partner were identified: age (both men and women), the duration of the partnership, and the number of children. However, a distinctive picture of "couples at risk" did not emerge: few (one in six) couples displayed three or more of the risk factors; in the majority (two-thirds) of couples with only one or two of the factors, at least one partner was HIV-positive.

At least one partner was positive in 29% of the couples with none of the identified risk factors. The study was conducted in an urban area with very high population density and HIV prevalence; the authors suggest that demographic risk profiles may be more distinctive in lower-prevalence areas.

The mean age among all persons tested was 34 years for men and 27 years for women; HIV prevalence was highest in 30- to 39-year-old men and 25- to 34-year-old women. Of the 8500 couples tested, both partners were HIV-negative in 51% of the couples, both were HIV-positive in 26%, and 23% of the couples were serodiscordant, with the man as the HIV-positive partner in 11% and the woman in 12%.

The couples studied had been together for a mean of seven years. HIV prevalence varied with length of partnership, but not always linearly. For women in partnerships of between one to eight years in length, prevalence remained stable at 40% to 43%; prevalence in women in longer partnerships was an average of 27%. The pattern was similar for men but with lower prevalence in the shortest partnerships: prevalence in men increased from 36% when in unions of less than three years, to 43% at six to eight years, then decreased to 30% for partnerships of longer than eight years.

The authors state that, although "CVCT is the most effective HIV prevention intervention for cohabiting couples in Africa, the largest group at risk for HIV infection in the world," very few couples in high-prevalence areas are tested together, as current programs emphasise individual counselling and testing. They believe their programme has "demonstrated that couples will come together for testing if financial and logistical obstacles are overcome."