BackgroundClient-initiated HIV counselling and testing has been scaled up in many African countries, in the form of voluntary counselling and testing (VCT). Test rates have remained low, with HIV-related stigma being an important barrier to HIV testing. This study explored HIV testing decisions in one rural and one urban district in Zambia with high HIV prevalence and available antiretroviral treatment.MethodsData were collected through 17 in-depth interviews and two focus group discussions with individuals and 10 in-depth interviews with counsellors. Interpretive description methodology was employed to analyse the data.Results'To know your status' was found to be a highly charged concept yielding strong barriers against HIV testing. VCT was perceived as a diagnostic device and a gateway to treatment for the severely ill. Known benefits of prevention and early treatment were outweighed by a perceived burden of knowing your HIV status related to stigma and fear. The manner in which the VCT services were organised added to this burden.ConclusionsThis study draws on social stigma theory to enhance the understanding of the continuity of HIV related stigma in the presence of ART, and argues that the burden of knowing an HIV status and the related reluctance to get HIV tested can be understood both as a form of label-avoidance and as strong expressions of the still powerful embodied memories of suffering and death among non-curable AIDS patients over the last decades. Hope lies in the emerging signs of a reduction in HIV related stigma experienced by those who had been tested for HIV. Further research into innovative HIV testing service designs that do not add to the burden of knowing is needed.

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Home-based voluntary HIV counselling and testing (HB-VCT) has been reported to have a high uptake, but it has not been rigorously evaluated. We designed a model for HB-VCT appropriate for wider scale-up, and investigated the acceptance of home-based counselling and testing, equity in uptake and negative life events with a cluster-randomized trial. Thirty six rural clusters in southern Zambia were pair-matched based on baseline data and randomly assigned to the intervention or the control arm. Both arms had access to standard HIV testing services. Adults in the intervention clusters were offered HB-VCT by local lay counsellors. Effects were first analysed among those participating in the baseline and post-intervention surveys and then as intention-to-treat analysis. The study was registered with www.controlled-trials.com, number ISRCTN53353725. A total of 836 and 858 adults were assigned to the intervention and control clusters, respectively. In the intervention arm, counselling was accepted by 85% and 66% were tested (n = 686). Among counselled respondents who were cohabiting with the partner, 62% were counselled together with the partner. At follow-up eight months later, the proportion of adults reporting to have been tested the year prior to follow-up was 82% in the intervention arm and 52% in the control arm (Relative Risk (RR) 1.6, 95% CI 1.4-1.8), whereas the RR was 1.7 (1.4-2.0) according to the intention-to-treat analysis. At baseline the likelihood of being tested was higher for women vs. men and for more educated people. At follow-up these differences were found only in the control communities. Measured negative life events following HIV testing were similar in both groups. In conclusion, this HB-VCT model was found to be feasible, with a very high acceptance and to have important equity effects. The high couple counselling acceptance suggests that the home-based approach has a particularly high HIV prevention potential.

HIV testing and counselling is a critical gateway to prevention and treatment. Yet, coverage remains insufficient, few couples are tested together and gender differences in access exist. We used an embedded mixed methods approach to investigate possible explanations for the high acceptance of home-based voluntary HIV counselling and testing (HB-VCT) in a pair-matched cluster-randomized trial in Zambia. A baseline survey included 1694 individuals in 36 clusters. Adults in 18 intervention clusters were offered HB-VCT by lay counsellors. Standard testing services were available in both trial arms. After the completion of the intervention, a follow-up survey was conducted in all trial clusters. In addition, 21 in-depth interviews and one focus group discussion were conducted with home-based VCT clients in the intervention arm. Informants favoured the convenience, confidentiality and credibility of HB-VCT. Counsellors were perceived as trustworthy owing to their closeness and conduct, and the consent process was experienced as convincing. Couple testing was selected by 70% of cohabiting couples and was experienced as beneficial by both genders. Levels of first-time testing (68% vs. 29%, p < 0.0001) and re-testing (94% vs. 74%, p < 0.0001) were higher in the intervention than in the control arm. Acceptance of HIV testing and counselling is dependent on stigma, trust and gender. The confidentiality of home-based VCT was essential for overcoming stigma-related barriers, and the selection of local counsellors was important to ensure trust in the services. The high level of couple counselling within HB-VCT may contribute to closing the gender gap in HIV testing, and has benefits for both genders and potentially for prevention of HIV transmission. The study demonstrates the feasibility of achieving high test coverage with an opt-in consent approach. The embedded qualitative component confirmed the high satisfaction with HB-VCT reported in the quantitative survey and was crucial to fully understand the intervention and its consequences.

BackgroundLow uptake of voluntary HIV counselling and testing (VCT) in sub-Saharan Africa is raising acceptability concerns which might be associated with ways by which it is offered. We investigated the acceptability of home-based delivery of counselling and HIV testing in urban and rural populations in Zambia where VCT has been offered mostly from local clinics.MethodsA population-based HIV survey was conducted in selected communities in 2003 (n = 5035). All participants stating willingness to be HIV tested were offered VCT at home and all counselling was conducted in the participants' homes. In the urban area post-test counselling and giving of results were done the following day whereas in rural areas this could take 1-3 weeks.ResultsOf those who indicated willingness to be HIV tested, 76.1% (95%CI 74.9-77.2) were counselled and received the test result. Overall, there was an increase in the proportion ever HIV tested from 18% before provision of home-based VCT to 38% after. The highest increase was in rural areas; among young rural men aged 15-24 years up from 14% to 42% vs. for urban men from 17% to 37%. Test rates by educational attainment changed from being positively associated to be evenly distributed after home-based VCT.ConclusionsA high uptake was achieved by delivering HIV counselling and testing at home. The highest uptakes were seen in rural areas, in young people and groups with low educational attainment, resulting in substantial reductions in existing inequalities in accessing VCT services.