Social science constantly seeks new ways to change sexual behaviour to prevent HIV/AIDS. One proven method is to increase the uptake of voluntary counselling and testing.
Project Accept is a potentially groundbreaking, large-scale HIV/AIDS-prevention trial, conducted in five sites in four countries. The five sites are in Vulindlela (outside Pietermaritzburg), Soweto, Tanzania, Zimbabwe and Thailand.
The study aims to compare the advantages, including cost-efficacy, of two VCT approaches to HIV prevention. The one approach is health-facility based VCT; the other uses a combination of strategies: mobilisation of the community around HIV testing plus sameday mobile VCT and referral to post-test support services once people know their status.
These strategies operate on the assumption that increased knowledge of HIV status is important to reduce stigma and to encourage preventative behaviour. As the study moves towards implementation of the intervention in April 2006, this article reflects on some of our preparatory work conducted in the last year.
The health –facility-ased VCT approach: We conducted interviews with 50 stakeholders involved in community, prevention, treatment, care and social support services in the Vulindlela area. The aim was to identify what VCT services existed in this rural community, as well as to identify stakeholders’ perceptions of current VCT services, and possible community responses to the intended mobile VCT service.
Stakeholders regarded the poor quality of the services provided in health facilities, the limited operating hours, and the lack of confidentiality surrounding HIV testing in these sites as key factors that limited uptake of VCT in this rural area.
Stakeholders had noted a small increase in the uptake of VCT since the introduction of rapid HIV testing, but generally felt that community members were reluctant to test because of the perceived lack of benefits available to them. Many felt that current VCT services tended to attract clients who were ill or symptomatic, and that this created an additional strain on service providers.
Most stakeholders had mixed feelings about the mobile VCT service we hoped to provide. Some thought that mobile VCT had advantages, such as greater accessibility and no transport and service costs for the community, and that this would encourage people to come forward. Others felt that because the mobile VCT will be branded as such (and likely to be associated with HIV and AIDS), many people would be reluctant to come forward for testing for fear of being stigmatised and discriminated against.
The mobile VCT pilot study approach: From the stakeholder interviews, it was clear that a good mobilisation strategy was essential. to rouse community interest and to encourage them to use the services. So we prepared communities a few weeks before the pilot, using multiple strategies, such as promotional material drop-offs in community homes and venues.
The mobile caravan was fully staffed and then rotated through various locations. Despite stakeholder reservations about possible community readiness for mobile VCT, we were extremely surprised by the immediate and positive response to the mobile VCT pilot service.
About 40% of the participants were recruited within the first three weeks of the pilot, with a definite drop in participation after that period. This decline was expected, as the number of people eligible for testing tends to decrease over time. What was unexpected was the steep uptake.
The positive response we received could be due to the community preparation activities we undertook as well as to the novelty and excitement that this mobile VCT caravan generated wherever it went. It also appeared that we were fulfilling a need in these communities and that if VCT is made more accessible, people are likely to make use of the opportunity to establish their HIV status.
Of the first-time testers, 82% were male and 68% were female. The mobile VCT service on the whole attracted a relatively equal number of males (47%) and females (53%) – an important finding regarding the potential of mobile VCT to reach men, who, for the most part, have not utilised VCT offered in settings that tend to attract women, like clinics or hospitals.
A further encouraging finding was the 83% of men and 84% of women who tested seronegative in our sample. Across both genders, more than half of those who participated in VCT fell into the ‘at risk’ 18–32 year old age categories. It appeared that mobile VCT had the capacity to reach young men and young women considered to be most at risk from HIV infection.
Our mobile VCT service saw clients who were generally well and came voluntarily to VCT because they were concerned about HIV risk, in contrast to the clients typically seen in health facilities that tend to be referred by a health professional for testing and are already showing signs of advanced HIV-related illnesses.
Client exit interviews conducted with 12% of our pilot sample confirmed that community members found many pleasing aspects about the rapid, same-day mobile VCT service. These included the accessibility and convenience of the on-site services, general client satisfaction with the professionalism of the service, the openness and knowledge of the counsellors providing the service, and the personalised risk-reduction counselling offered by the study.
Most participants (93%) reported that they would recommend the service to their family and friends because they felt it was important for people to know their status and to be educated to behave responsibly regarding HIV/AIDS.
So, despite stakeholder concerns that stigma and discrimination around HIV and AIDS might limit uptake of mobile VCT services, our experience in the pilot was the reverse. However, to be effective, mobile VCT works best when accompanied by a comprehensive and sustained community mobilisation strategy around HIV testing. As this is what the intervention intends to do – link VCT with community mobilisation around HIV testing and post-test support services – we feel encouraged about the potential of this novel approach to VCT to make a difference in the lives of communities in which we intervene.
Eventually the project aims to test approximately 12 500 people, apart from those who access VCT through health services, before measuring the impact through a follow-up community-based survey with testing for recent HIV infection. And, finally, the communitybased VCT effort will be costed with the view to extend it to the rest of the district and potentially the province, and possibly the country as a whole.
- (Source: Human Science Research Council)