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.
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).
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.
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.
sub-Saharan Africa rates of heterosexual HIV
transmission among couples in stable relationships vary from 30% to 70-90%.
estimated 6.2% of couples are in discordant relationships (where one is
HIV-positive and the other is HIV-negative).
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.
Wall and colleagues undertook a prospective random cohort study from July 2004
until December 2005 to look at predictive factors for CVCT.
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.
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.
Influence Network Leaders (INL) were recruited who then nominated 118 agents
and supported their efforts by publicly endorsing CVCT.
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
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.
agent distributed an average of 212 invitations resulting in an average of 38
couples tested for each agent.
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.
agents were more successful among couples living together, while younger agents,
notably those who were unemployed, did better with couples not living together.
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
factors for increased uptake of CVCT among couples living together included
older age of the couples and the longer the time of the relationship.
couples living together older men were more likely to test, and conversely
among those not living together it was younger men.
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.
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
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.
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.
authors stress that during this time pregnant women and their partners were not
routinely tested together and disclosure was neither sought nor documented.
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.
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.”