Many studies have found that VCT is effective as a strategy for facilitating behaviour-change around both preventing HIV and early access to care and support 3.
Couple pre- and post-test counselling, when conducted in a skilled manner, has been shown to be relatively more beneficial through facilitating disclosure of HIV status and contributing to behaviour change including risk assessment and risk reduction planning.
In addition, particularly for women in countries where gender inequity is significant, couple counselling may play a role in reducing gender-based violence, discrimination, isolation and abandonment experienced by women who test positive.
Furthermore, providing services to couples can be relatively more cost efficient.
Costs and feasibility
The initial high cost of VCT - attributable to facility constructions and/or renovation; the cost of procuring and distributing HIV test kits and confirmatory reagents; training service providers to ensure high quality and sustainable counselling services including supportive supervision; and promotional and community mobilization activities - is gradually declining with the introduction of rapid test kits (refer to fact sheet on HIV test kits), with economies of scale, and with increased use of lay counselors and volunteers. Start up cost for freestanding sites are high as compared to integrated into existing services and infrastructures.
As demand increases for VCT it becomes increasingly likely that appropriately selected and trained volunteers (lay counselors) will be needed to provide the service or, at least, provide the HIV/AIDS information aspects. This may greatly expand the reach and sustainability of the service.
Costs can also be reduced and time saved by pre-test information sessions in groups, a strategy already being applied in few antenatal settings.
Confidentiality or secrecy
While confidentiality should be a necessary element of quality VCT service, in some cultural contexts, overstressing the confidential aspect of HIV/AIDS has fed into increased stigma, discrimination and fear.
In parts of sub-Saharan Africa the concept "shared confidentiality" 4 is more current than strict confidentiality, in line with traditional patterns of family communication, interaction and decision-making.
In designing VCT services, these cultural perspectives need to be taken into account.
The initial ELISA (Enzyme Linked Immunosorbent Assay) test, Western blot and other HIV antibody tests are increasingly being replaced by high-quality rapid HIV tests that give results in a few minutes. Many advantages accrue from their use: clients need not return for a second visit to learn their results; the test can be administered by a counselor rather than by a laboratory technician; and the rather costly laboratory facilities and equipment are not required.
The test kits are highly portable, facilitating mobile and community outreach VCT services. They are highly specific and sensitive, giving very few false results, and confirmatory tests can be performed using rapid tests by serial or parallel testing methods 5.
Rapid HIV tests do incur certain disadvantages, however. Sometimes people do not believe that such a simple test can accurately convey such serious information as an HIV result. Some view the waiting period for test results as a time for reflection, giving pre-test counselling a greater impact and allowing individuals to cope better with a positive result.
Potential outcomes of VCT
A few studies have revealed that when counselling is not of high quality, or in the absence of a supportive environment and back-up services, VCT has lead to negative client outcomes.
Without support, some HIVpositive clients become so distressed or angry that they increase sexual risk behaviour and/or suffer depression and anxiety.
More common are experiences of stigma, discrimination, violence and rejection by partners, families or communities. Women, especially, often fear and experience violence and rejection from their partners or husbands, making many women reluctant to share their HIV results.
Reducing these risks requires VCT services to offer high quality counselling, with sufficient time to cover the main areas of concern, and the possibility of follow up and ongoing counselling and support.
The services should be able to provide, or refer, clients as required, for further support, including for medical treatment, nursing, psychosocial support and counselling, nutritional, material and other assistance.
Post-test and HIV/AIDS support clubs can play a valuable role in motivating safer sexual behaviour in both HIV-negative and -positive clients, as well as providing other needed support.