This prospective study evaluating health centre‐based VCT services found that clients attending services reported a significant reduction in high‐risk sexual behaviours from baseline (before services) to the 6‐month (average 7.5 month) follow‐up. VCT clients reported a significant decrease in multiple sexual partners and STI symptoms. Condom use, although increased, was still relatively low at follow‐up, with 95% of sexually active clients reporting any unprotected sex at baseline compared with 89% at follow‐up. Average episodes of unprotected sex with a non‐primary partner fell from 93% to 49% in those reporting sex with a non‐primary partner. There were very high rates of disclosure by HIV‐negative clients, but low rates for HIV‐positive clients. VCT did not increase negative life events reported regardless of the outcome of the test.
As part of a larger operational research study evaluating new strategies for VCT provision, the design has limitations, as it could not include a control group or biological measures of STI. Social desirability bias may have led to under‐reporting of risky behaviours. In addition, risky behaviours and events may prelude a visit for VCT and may not be typical of a person's behaviour and therefore may “regress” with time regardless of any intervention effect. This is another limitation of an uncontrolled intervention study where people self‐select for the intervention. However, in this study, 58% of clients stated no specific trigger for attending for VCT (just wanting to know status), and only 17% said that they had attended because of risky behaviour. Only 19% were internal referrals from within the clinic (eg, STI attenders). High rates of recruitment and follow‐up meant that the study population appeared to broadly represent those eligible, although some under‐recruitment and increased loss to follow‐up meant that the study population does under‐represent HIV‐positive clients. In addition, the participants may not have been representative of VCT attenders in Kenya generally. These data were collected in the pre‐antiretroviral era; any recommendations must be made cautiously, as behaviour may have changed with antiretroviral availability. However, this new era 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 (reported elsewhere24
). There was also poor correlation between individual risk perception and HIV result, as noted elsewhere,25
making counselling and testing a vital tool in this population.
In addition to a reduction in the number of sexual partners, decrease in STI symptoms, and a small increase in condom use, there was also a trend for change in partner type, with a reduction in sexual intercourse with non‐primary partners after VCT. These changes did not vary by gender, age, marital status or HIV test outcome.
- Clients attending primary healthcare‐based voluntary counselling and testing (VCT) services showed significant reductions in the number of sexual partners, fewer sexually transmitted infection symptoms, and increased condom use at the 6‐month follow‐up after VCT.
- High background rates of violence were recorded, with no increase in life events noted after VCT.
- VCT in healthcare centres should be considered alongside diagnostic counselling and testing to aid primary prevention opportunities, which are vital as incident HIV infections continue to rise, exceeding treatment enrolment.
The concurrence of a reduction in numbers of sexual partners with reduction in reported STI symptoms suggests a real change, but without a control group it is not possible to conclude that this is due to the intervention. However, the magnitude of the change and the clients' own perceptions of their HIV prevention behaviour before and after the intervention support this interpretation. Behaviour change was mainly via partner reduction not condom use, which may go against social desirability bias.
Behaviour change has been described for other VCT services.4,25,26,27,28
It is encouraging that health centre VCT may mirror these successes. It is disappointing that this study, like others26
but unlike the multicentre efficacy trial,4
did not find more impact on condom use despite good knowledge and access to condoms. This may be related to low baseline rates of condom use and prevalent negative attitudes towards condoms.
Disclosure rates for HIV‐positive clients were low, although similar to other studies.17,29
This highlights the importance of seeking improved strategies for disclosure for HIV‐positive clients—for example, using couple counselling.18,27
High rates of HIV‐negative disclosure suggest low stigma for HIV testing itself.
In comparison with earlier reports,17
this study concurs with the multicentre trial in recording no significant harm caused by VCT.18
Our findings need to be interpreted with care in view of the small numbers of HIV‐positive clients involved and low disclosure rates. Importantly, we found high background rates of violence; this has also been noted in studies in other countries.30
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 pretest 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 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.