Complex relationships between voluntary counselling and testing and behaviour change in northwest Tanzania

The impact of voluntary counselling and testing services on sexual behaviour change and HIV incidence: observations from a cohort study in rural Tanzania.

Cawley C, Wringe A, Slaymaker E, Todd J, Michael D, Kumugola Y, Urassa M, Zaba B. BMC Infect Dis. 2014 Mar 22;14:159. doi: 10.1186/1471-2334-14-159.

Background: It is widely assumed that voluntary counselling and testing (VCT) services contribute to HIV prevention by motivating clients to reduce sexual risk-taking. However, findings from sub-Saharan Africa have been mixed, particularly among HIV-negative persons. We explored associations between VCT use and changes in sexual risk behaviours and HIV incidence using data from a community HIV cohort study in northwest Tanzania.

Methods: Data on VCT use, sexual behaviour and HIV status were available from three HIV serological surveillance rounds undertaken in 2003-4 (Sero4), 2006-7 (Sero5) and 2010 (Sero6). We used multinomial logistic regression to assess changes in sexual risk behaviours between rounds, and Poisson regression to estimate HIV incidence.

Results: The analyses included 3 613 participants attending Sero4 and Sero5 (3 474 HIV-negative and 139 HIV-positive at earlier round) and 2 998 attending Sero5 and Sero6 (2 858 HIV-negative and 140 HIV-positive at earlier round). Among HIV-negative individuals VCT use was associated with reductions in the number of sexual partners in the last year (aRR Seros 4-5: 1.42, 95% CI 1.07-1.88; aRR Seros 5-6: 1.68, 95% CI 1.25-2.26) and in the likelihood of having a non-cohabiting partner in the last year (aRR Seros 4-5: 1.57, 95% CI 1.10-2.25; aRR Seros 5-6: 1.48, 95% CI 1.07-2.04) or a high-risk partner in the last year (aRR Seros 5-6 1.57, 95% CI 1.06-2.31). However, VCT was also associated with stopping using condoms with non-cohabiting partners between Seros 4-5 (aRR 4.88, 95% CI 1.39-17.16). There were no statistically significant associations between VCT use and changes in HIV incidence, nor changes in sexual behaviour among HIV-positive individuals, possibly due to small sample sizes.

Conclusions: We found moderate associations between VCT use and reductions in some sexual risk behaviours among HIV-negative participants, but no impacts among HIV-positive individuals in the context of low overall VCT uptake. Furthermore, there were no significant changes in HIV incidence associated with VCT use, although declining background incidence and small sample sizes may have prevented us from detecting this. The impact of VCT services will ultimately depend upon rates of uptake, with further research required to better understand processes of behaviour change following VCT use.

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Editor’s notes: This study focused on seven years of serological surveillance surveys and voluntary counselling and testing data (VCT) from a community cohort in northwest Tanzania. The aim of the study was to examine correlations between VCT use and changes in sexual behaviour. In general, it is often assumed that VCT helps to reduce HIV incidence by making people aware of HIV and their status. However, further investigation in previous studies has shown that this is not always the case. This particular study revealed relatively low uptake of VCT and low condom use, but VCT was associated with a reduction of sexual partners in HIV-negative individuals. The study was unable to detect a significant association between HIV incidence and VCT, nor any changes in behaviour among HIV-positive individuals. It is clear from the nuanced results of this study that relationships between VCT and behaviour change are complex and variable. Qualitative research would help us to understand what other issues influence this relationship and could shed light on the low uptake of VCT in this area. Perhaps an updated systematic review of VCT and sexual behaviour studies in combination with qualitative research could help in better understanding this dynamic relationship.

United Republic of Tanzania
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