Study finally backs up conventional wisdom: VCT does reduce risky sex in Africa

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Kenyans attending rural and urban primary healthcare-based voluntary counselling and testing (VCT) services reported significant reductions in the number of sexual partners, fewer sexually transmitted infection symptoms, and increased condom use – albeit from a very low base – six months following an HIV antibody test, according to the results of an observational study of behaviour change and life events published in Sexually Transmitted Infections, published online on 8th November.

The investigators conclude that their study “suggests that future health centre-based VCT services emphasising prevention outcomes should be considered in counselling and testing packages, alongside [diagnostic counselling and testing] and antiretroviral treatment programmes, to ensure that substantial prevention opportunities are not missed.”

The findings offer a more optimistic assessment of VCT's impact on sexual behaviour than a study conducted in Zimbabwe, presented in June at the South African AIDS Conference, which showed that a negative HIV test result was associated with an increase in risky sexual behaviour, and that offering VCT had no impact on HIV incidence.

Glossary

VCT

Short for voluntary counselling and testing.

disclosure

In HIV, refers to the act of telling another person that you have HIV. Many people find this term stigmatising as it suggests information which is normally kept secret. The terms ‘telling’ or ‘sharing’ are more neutral.

observational study

A study design in which patients receive routine clinical care and researchers record the outcome. Observational studies can provide useful information but are considered less reliable than experimental studies such as randomised controlled trials. Some examples of observational studies are cohort studies and case-control studies.

pilot study

Small-scale, preliminary study, conducted to evaluate feasibility, time, cost, adverse events, and improve upon the design of a future full-scale research project.

 

bias

When the estimate from a study differs systematically from the true state of affairs because of a feature of the design or conduct of the study.

The findings also provide the most solid evidence to date backing the frequently repeated assertion that VCT is a cornerstone of HIV prevention.

However, this study – nested in a pilot study of integrating VCT into government primary healthcare centres in Kenya – took place in 1999, before antiretroviral therapy and diagnostic counselling and testing were in place in Kenya, and when VCT existed predominantly in a few urban private clinics, NGOs and district hospitals.

Out of a possible 743 consecutive clients seeking VCT at three primary health centres – two in the rural Thika district and one in urban Nairobi – throughout 1999, 540 (73% of those eligible) were enrolled equally across clinics. A total of 14.7% tested HIV-positive.

The average time to follow-up was 7.5 months (median 6.9 months). Overall, 401 (74%) were successfully followed up, although the investigators concede that the follow-up group – of whom 12.3% had tested HIV-positive – under-represents HIV-positive clients, female HIV-positive clients in particular. Clinic clients reporting multiple sex partners also tended to be lost to follow-up.

Of note, the majority (65.5%) of clients perceived very little or no chance of testing HIV positive, with only a loose correlation between their expectations and the HIV result itself. Notably, three-quarters (27/36) of clients who thought that they were ‘likely’ or ‘very likely’ to test positive ended up testing HIV negative.

Sexual activity and partner numbers

During their VCT visit, the majority of clients from all clinics (98% of women and 90% of men) reported either one primary partner or no sexual activity over the preceding two months.

A total of 16% (24% of men and 8% of women) reported two or more partners in the preceding six months. At follow-up, this reduced to 6% (10% of men and 2% of women; p

’ABC’ and condom use

Condoms were the least popular prevention measure reported at the VCT visit. Just one third of clients reported ever using a condom, and only 6% reported using condoms consistently with their primary partner; none used condoms consistently with non-primary partners. Consequently, 95% of casual sex acts and 77% of commercial sex acts reported were unprotected.

Immediately after receiving their result, 47% clients reported that they planned to be faithful to one partner, whereas just 23% planned to use condoms. At follow-up, only half of those planning condom use had actually used them. Yet, 85% of clients reported that condoms were easily accessible to them, and only 6% said that they could not afford condoms.

Although condom use remained low at follow-up, sexual intercourse was more often protected compared to baseline (from 95% to 89%; p=0.021). This was primarily due to negative attitudes towards condom use, which improved but remained high at follow-up. Embarrassment in using condoms fell from 42% to 33% (p

Sexually transmitted infection symptoms

Forty per cent of VCT clients reported STI symptoms in the preceding six months, and around two-thirds of those reporting symptoms had sought treatment.

At follow-up, significantly fewer STI symptoms were reported (40% vs. 15%; p

Impact on disclosure

Perhaps unsurprisingly, the investigators found that post-VCT there were very high rates of disclosure by HIV-negative clients, but much lower rates for HIV-positive clients. “This,” write the investigators, “highlights the importance of seeking improved strategies for disclosure for HIV-positive clients—for example, using couple counselling.”

Before receiving results, 93% planned to disclose if they were HIV-positive. However, at follow-up, 55% of HIV-positive and 82% of HIV-negative clients had disclosed the results of their test. There were no reported differences in disclosure by gender. The investigators note that there was a high baseline rate of physical abuse or neglect by family – 8% of clients reported these – but that these were essentially unaltered by an HIV-positive result.

Study limitations and cautions

The investigators point out several limitations to this study. Notably, there was no control group; social desirability bias may have led to under-reporting of risky behaviours; the study population under-represented HIV-positive clients; and participants may not have been representative of VCT attendees in Kenya generally.

In addition, the investigators note, “these data were collected in the pre-antiretroviral era; any recommendations must be made cautiously, as behaviour may have changed with antiretroviral availability.”

Nevertheless they argue that the availability of treatment “has also moved the focus towards diagnostic testing, and it remains important to consider missed opportunities for prevention. Many VCT clients failed to perceive their higher HIV risk compared with the general public. There was also poor correlation between individual risk perception and HIV result, making counselling and testing a vital tool in this population.”

Discussion and conclusion

The investigators write, “at this time of emphasis on HIV treatment, it is critically important to focus on primary HIV prevention strategies. This study found that clients planned risk reduction after pre-test counselling and showed significant changes in sexual behaviour at follow-up. These findings are in line with randomised controlled trials suggesting that primary health centre services can help primary prevention efforts. Ongoing monitoring for negative impacts is recommended.

“The challenge to policy makers,” they conclude, “is to now weigh the prevention benefits of VCT against the possibility that it may not offer greatest efficiency in increasing treatment uptake. This study suggests that future health centre-based VCT services emphasising prevention outcomes should be considered in counselling and testing packages, alongside DCT and antiretroviral treatment programmes, to ensure that substantial prevention opportunities are not missed.”

References

Arthur G et al. Behaviour change in clients of health centre-based voluntary HIV counselling and testing services in Kenya. Sex Transm Infect 83:541–546, 2007.