Implementation and Operational Research: Evolution of Couples' Voluntary Counseling and Testing for HIV in Rwanda: From Research to Public Health Practice

Abstract

Background:Couples' voluntary HIV counseling and testing (CVCT) is a WHO-recommended intervention for prevention of heterosexual HIV transmission which very few African couples have received. We report the successful nationwide implementation of CVCT in Rwanda.Methods:From 1988 to 1994 in Rwanda, pregnant and postpartum women were tested for HIV and requested testing for their husbands. Partner testing was associated with more condom use and lower HIV and sexually transmitted infection rates, particularly among HIV-discordant couples. After the 1994 genocide, the research team continued to refine CVCT procedures in Zambia. These were reintroduced to Rwanda in 2001 and continually tested and improved. In 2003, the Government of Rwanda (GoR) established targets for partner testing among pregnant women, with the proportion rising from 16% in 2003 to 84% in 2008 as the prevention of mother-to-child transmission program expanded to >400 clinics. In 2009, the GoR adopted joint posttest counseling procedures, and in 2010 a quarterly follow-up program for discordant couples was established in government clinics with training and technical assistance. An estimated 80%–90% of Rwandan couples have now been jointly counseled and tested resulting in prevention of >70% of new HIV infections.Conclusions:Rwanda is the first African country to have established CVCT as standard of care in antenatal care. More than 20 countries have sent providers to Rwanda for CVCT training. To duplicate Rwanda's success, training and technical assistance must be part of a coordinated effort to set national targets, timelines, indicators, and budgets. Governments, bilateral, and multilateral funding agencies must jointly prioritize CVCT for prevention of new HIV infections.

High risk exposure to HIV among sexually active individuals who tested negative on rapid HIV Tests in the Tshwane District of South Africa—The importance of behavioural prevention measures

“…The trend of higher risk of HIV infection among unmarried individuals compared to the married ones ( Table 2 ) has been observed in a previous South African study [ 21 ]. The finding of HIV infections among married participants has also been observed by many other studies in the sub-Saharan Africa [ 21 – 24 ]. Extramarital affairs could be the possible source of HIV infection in married couples [ 23 ].…”

HIV Incidence and Predictors of HIV Acquisition From an Outside Partner in Serodiscordant Couples in Lusaka, Zambia

“… 4 – 6 Several African countries are adopting couples-based HIV counseling and testing as an HIV prevention and care intervention, thus more couples are becoming aware of each other's HIV status, and many find out that they are HIV-serodiscordant. 7 Despite this increased knowledge of HIV-serodiscordance among couples, there has been less focus on effective messages and interventions to prevent HIV acquisition from outside partners. Appropriate and effective interventions for HIV prevention in serodiscordant couples depend on accurate assessments of the sexual risk behaviors among the HIV-positive and HIV-negative partners and understanding their own sexual behaviors with other men and women.…”

Rwandan stakeholder perspectives of integrated family planning and HIV services

“…26 However, differentiated reimbursement schemes, proportional to the time and costs that clinics incur to provide LARC methods, have been considered and implemented in other locales, for example in Burundi where the payment for new oral and injectable FP users and all return clients was $2.00USD, while for implants/IUDs it was $5.00USD. 27,28 The importance of male involvement, already a nationwide norm with joint HIV testing of >80% of pregnant women and their partners, 9 was also mentioned as an important means of increasing effective LARC use.…”

“…8 Heterosexual cohabiting couples are the largest risk groups for both unintended pregnancy and HIV, and Rwanda is the only country to implement couples’ voluntary counseling and testing (CVCT) programs nationwide 9 as a high impact HIV prevention strategy. 10 …”

“…9 Using the same comprehensive approach, RZHRG is now establishing LARC provision as standard of care in FP programs, and integrating FP services with couple-focused HIV testing programs. To ensure successful integration, efforts must move past the clinic staff and client levels to engage stake-holders at the policymaker and funding agency levels.…”