In an African capital city where very few couples have jointly tested for HIV, a promotional programme using INLs and INAs prompted approximately 100 couples/month to seek CVCT. INA network, occupation, marital status and testing history, as well as couple cohabitation status and the INA–invitee relationship influenced invitation success. Invitations delivered to the couple, in the home, and invitations initiated by the woman partner were also significant CVCT uptake predictors.
CBOs/NGOs and health network INAs were more successful than faith-based or private sector INAs. CBO/NGO networks included parent-teacher, legal aid, skills training and health information organisations. Health networks included clinical officers, nurses, home healthcare visitors, community health workers, neighbourhood health committee members and traditional birth attendants. The private sector included individuals who were self-employed or those involved in providing the public with goods or services. Previous studies have similarly demonstrated the ability of influential people to effectively disseminate information and change attitudes and behaviours towards HIV in sub-Saharan Africa.16–18
Unlike health and CBO/NGO INAs, private sector INAs may have been preoccupied with income generation and/or did not have similar opportunities to integrate CVCT promotions into their daily routine. The marginal performance of faith-based INAs was surprising given Zambia is strongly religious; however, though religious leaders have opportunities to promote from the pulpit, the stigma associated with sexually transmitted infections (STIs) may inhibit open discussion on CVCT.17
Cohabiting couples were more likely than non-cohabiting couples to test, and married INAs delivered more successful invitations than unmarried INAs. Fear of stigma among married couples is common,9
and perhaps married INAs were able to more successfully overcome this barrier with their fellow married couples. INAs who previously tested for HIV with a partner were also more successful than those who had not tested, likely due to their first hand knowledge of CVCT procedures and ability to speak personally to perceived CVCT barriers.
INAs socially acquainted with the invitee were more successful versus those who were previously unacquainted. The strength of INA–invitee relationship may facilitate open discussion on CVCT and engender confidence. INAs inviting the couple together versus either partner alone, potentially removing pressure for one partner to propose testing to the other, were also more successful. Previous studies support the effectiveness of couple-level-targeted prevention strategies.13
Although most invitations were initiated by INAs, when the woman partner initiated contact with the INA, the CVCT uptake increased. This finding likely reflects pre-existing motivation to discuss or participate in CVCT.
Invitations delivered in the home versus community were more effective. Previous studies indicate that home and workplace HIV counselling and testing promotions are more successful in Zambia, Uganda and Malawi relative to community locations.32–35
These findings are likely due to increased discretion and comfort associated with home settings.
Results from a similar study using both INLs and INAs in Kigali, Rwanda highlight country-specific similarities and differences. Similar to Zambia, Rwandan health INAs were more successful relative to private network INAs. Married Rwandan INAs were more successful than single INAs, and cohabiting couples were more likely to test than non-cohabiting couples in univariate analyses. We similarly found that invitations delivered to couples socially acquainted with the INA, woman partner initiated contact and invitations delivered at home were more successful in multivariate analyses in Rwanda. In contrast to this study, Rwandan faith-based INAs were more successful in univariate analyses relative to private network INAs, and the overall INA success rate in Rwanda was higher (18%). Mobile units were also associated with increased testing in Rwanda.20
We were surprised that the mobile unit was not predictive of testing in this analysis as in Rwanda, not because of mitigated transportation costs, which were reimbursed, but because of the increased convenience and decreased time commitments engendered by mobile testing. More research is needed to determine why the mobile testing units did not increase uptake.
Kigali and Lusaka, though both capital cities, differ in several important ways: Kigali has a monolingual population of 800 000 with easy and inexpensive transportation. In contrast, Lusaka's 1.7 million inhabitants represent all 73 Zambian languages/dialects, the city is large and transportation is expensive. Another study in the Bemba-speaking Copperbelt region of Zambia combined INA promotions with mass media strategies in two cities of 600 000 each and obtained success rates between those found in Lusaka and Kigali.14
These linguistic and infrastructural differences highlight the importance of testing and adapting network-based promotional models to different environments.
Results from a pilot study of promotions in Lusaka with 33 INAs (no INLs) showed that, while invitation-level predictors were similar to those found in this larger study, the small sample size did not allow simultaneous detection of INA-level, couple-level and invitation-level characteristics in hierarchical analysis.13
Similarly, the Copperbelt study described previously did not examine INA-level, couple-level or invitation-level predictors of success.14
The exclusion of the 70 INAs who did not achieve 1.5% success was considered necessary in order to determine the INA-level predictors of successful invitation delivery among INAs not returning fraudulent invitation receipts. We acknowledge that this exclusion may discount INAs who were poor performers in addition to INAs returning fraudulent receipts thereby reducing the generalisability of our findings to more productive INAs.
Overall, this study demonstrated the feasibility of CVCT promotions in Lusaka, and we believe success rates could be considerably increased by utilising the modifiable predictors of CVCT uptake identified: recruiting INAs who have tested with partners, focusing invitations on INA acquaintances, issuing invitations to couples and in a discreet location and utilising INAs from CBOs/NGOs and health networks. It should be noted that most of the statistically significant aORs are close to the null, suggesting cautious interpretation of these associations. More research is especially needed to encourage faith-based leaders in Zambia to promote CVCT more effectively.