Acceptability of a Kenyan‐style VCT service to UK African communities
Overall, most participants felt that community‐based HIV VCT would be acceptable to African communities in London, provided that steps were taken to protect clients' confidentiality and support the newly diagnosed. Participants identified several positive aspects to the service (box 1). These included the benefits of receiving HIV test results promptly through the use of rapid tests, making testing more accessible by bringing it “into the community”, receiving quality counselling, increasing community ownership of HIV prevention initiatives, and employing people living with HIV.
However, participants also identified three barriers to acceptability: (a) fear of HIV‐related stigma within UK African communities; (b) anxiety about breaches of confidentiality; (c) concerns about the potential lack of professionalism within the service.
Box 3: Targeting Africans
“If you target Africans only, they just feel targeted. Maybe they say, they think I am carrying it. But if it is targeting everyone, then that is better. And also we say we will be targeting African communities, but many Africans don't have that feeling of belonging to a ‘community'. Which community are you talking about? They never felt part of a community so it's not their problem.”
Female participant (Burundi), mixed group
Most participants thought that translating the LVCT model for London would be challenging because of perceived differences in levels of HIV stigma between African and European settings. Many argued that black Africans face stronger HIV stigma in the UK than in parts of eastern and southern Africa, where media and educational campaigns have increased HIV awareness, and where people living with HIV are more visible (box 2). Participants also highlighted that HIV stigma among UK African communities is compounded by racism and suspicions of health tourism among the wider community. Indeed, some participants feared that targeting black Africans for VCT would reinforce existing discrimination towards Africans and further deter people from finding out their status.
Box 4: Lack of confidentiality within the community
“I am an African, and I still go back to Africa, and the fear of someone back home knowing what my status is…”
Male participant (Uganda), positive group
“People's biggest fear is their result being known in their particular community, (…) the fear of ‘do they know my auntie, do they know my…' even if they are supposed to be confidential, that for me would be the biggest concern.”
Female participant (Zambia), mixed group
“I think going to the GUM clinic one can feel quite anonymous whereas if you go to a community‐based service someone from the community might recognise you and there is always the danger that they might tell someone else.”
Male participant (Sierra Leone), young people's group
Participants specifically debated the pros and cons of having a VCT service targeting African communities in London (box 3). Although some thought that an “African‐owned” VCT service would increase community involvement in HIV prevention and care, several also felt that African communities in London were both too heterogeneous and too constrained by stigma to endorse a targeted service. Some advocated routine testing as a destigmatising intervention, citing the example of antenatal care screening in the UK.
The second concern voiced by participants focused on potential breaches of confidentiality within community‐based settings. Some feared that people from their community would see them accessing VCT, or that staff would disclose clients' status to others outside the service (box 4). Participants also thought that community‐based centres would quickly become identified as “testing venues”, and that this would deter clients afraid of being seen by others from their community.
Box 5: Importance of care pathways
“I think a major challenge will be the follow‐up. Supposing the test comes out positive… Because the trauma suffered when you are HIV positive, what will happen? After you have tested in a community setting, what kind of follow‐up will be there?”
Male respondent (Uganda), positive group
Finally, participants were unsure about the ability of trained community‐based VCT staff to maintain professional standards, ensure the quality of counselling, and give appropriate support to those testing positive (box 5). They discussed the appropriateness of employing non‐healthcare workers to run community‐based VCT services; older participants and those living with HIV generally felt this was a good idea, whereas others thought it would impact on the quality of counselling and jeopardise efficient referrals to sexual health services.
Box 6: Increasing acceptability
“It is not out there in my college, you know, that you could see signs, that there is counselling over there or that kind of stuff. They do not know anything about it. If you can get the counsellors out of their offices to go around and talk about the work, it would help. (…)”
Female participant (Zimbabwe), young people's group
Participants identified several ways of making a community‐based VCT service more acceptable. Firstly, all groups suggested carrying out intensive community sensitisation in churches, schools and African social venues before opening the VCT service (box 6). The importance of community mobilisation was also emphasised to us by staff from LVCT Kenya when they recalled the early days of their service (A Njeri, personal communication, 2 March 2007). Secondly, participants advised the research team to draw on the experience of local African CBOs in order to promote and run the service. They also suggested alternative VCT models, such as mobile VCT, or offering other general health checks along with HIV testing. Finally, a consensus emerged across most groups that people living with HIV should be involved in VCT as counsellors and community mobilisers (box 7).
Box 7: Involving people living with HIV
“In a way I would say you [as a person living with HIV] could become counsellors, because you have the experience, you are now the living example. You have more experience than anybody who comes in!”
“Most of the HIV positive people who are living here are struggling. They are struggling to work. And this is work that we can do!”
Male & female participants (Uganda & Zambia), positive group
Adapting the LVCT model for the UK raises several challenges in relation to service delivery. Workshop participants identified three specific requirements for a London community‐based VCT service: (1) efficient referrals to sexual health services; (2) a testing algorithm and quality assurance scheme for counselling and testing; (3) training guidelines for VCT counsellors.
One of the biggest concerns for participants in this study was to ensure support to the newly diagnosed and fast referrals to HIV services. Whereas many Kenyan VCT sites provide treatment and support, community‐based VCT services in the UK must refer clients to sexual health services for follow‐up care. Participants in our study feared that poorly managed referrals would leave clients distressed and unsupported. The main recommendation put forward to improve referrals was to involve staff from sexual health clinics in the VCT service as “on call” liaison staff.
Testing and quality control
In the LVCT model, two rapid HIV tests are used to determine a client's serostatus. In the UK, however, a rapid HIV test result must be confirmed with a laboratory‐based ELISA.19
Community‐based VCT should therefore involve a single rapid HIV screening test, with a confirmatory test in sexual health services in case of a reactive result.6
Quality control should be conducted in a reference laboratory linked to a sexual health clinic. A local point of care test service committee would then set up a process for quality control and ensure that counsellors are trained and certified in the use of rapid HIV tests.19,20
In the UK, services offering rapid HIV tests require clinical pathology accreditation. As discussed above, the clinical pathology accreditation does not approve of non‐clinical staff interpreting test results, and community‐based VCT services currently have to employ healthcare workers.19
The possibility of training non‐healthcare workers to offer testing in African CBOs should, however, be explored; the recent rollout of rapid HIV tests in US CBOs serving high‐risk populations and the experience of African VCT organisations have demonstrated that trained non‐clinical staff are able to offer high‐quality VCT services.14,21
Training VCT counsellors
In the UK, restrictions around allowing non‐clinical staff to carry out testing means that current community‐based VCT sites must employ sexual health clinic staff. Although participants saw benefits to this approach, they also felt that allowing trained non‐clinical staff to carry out testing would be appropriate as long as referrals were efficiently managed. VCT guidelines and training programmes designed by LVCT and the Kenyan National HIV Taskforce could be adapted for other settings, including the UK.16,22
The LVCT training programme would adequately meet the knowledge and skills requirements needed to deliver pre‐ and post‐test counselling as recommended by the British HIV Association.6,23
Our workshop participants also argued that specific training should be given to UK VCT counsellors on several issues: (1) dealing with questions about immigration status and entitlement to HIV treatment; (2) discussing prevention of mother‐to‐child transmission; and (3) supporting VCT counsellors living with HIV.