University of Zambia Medical Library

HIV Counselling and Testing in Zambia (KARA Counselling & Training Trust: August 1997)

• To disseminate the findings of 3 studies carried out by Kara Counselling and Training Trust (KCTT)
• To invite all other organisations, governmental and non-governmental to share their experiences in this field
• To discuss if and how HIV c&t fits into the HIV prevention programme for Zambia

Background: HIV c&t in Zambia:
Voluntary HIV counselling and testing (c&t) services were first set up in Zambia by KCTT in November 1992. Initially funds for HIV testing were provided by the Zambart Project and people who tested seropositive were offered entry into a trial of tuberculosis preventive therapy by the Zambart Project at University Teaching Hospital (UTH). Following this more substantial funding was provided by USAID and KCTT opened up counselling centres in Chawama and Helen Kaunda compounds in addition to their established centres at Thornpark, Kara House and Hope House. Initially demand for HIV c&t was relatively low and the majority of people who wanted an HIV test were symptomatic. This was reflected in the high HIV seropositivity rate of our initial attenders.

HIV c&t has an important role in the prevention of HIV transmission, as well as providing support for those testing seropositive and attempting to destigmatize HIV. If asymptomatic people could be encouraged to be tested many would test seronegative. For these people, knowledge of their HIV status would enable them to make changes in their sexual behaviour to remain negative. KCTT therefore trained community workers to invite people for HIV c&t. This approach was successful and the numbers of people attend for c&t at the KCTT centres rose enormously, and the rate of HIV seropositivity among attenders fell. However there were still barriers to HIV testing particularly from cohabiting couples and there was a high rate of people who did not return to collect their results among those people who were invited for HIV testing when compared with those who were self-motivated.

Research undertaken:
Three studies, supported by WHO/UNAIDS have been carried out during this period to look at various aspects of the HIV c&t process:

Barriers to HIV Testing: Why 9 in 10 Couples Refused HIV Tests in Lusaka:

• Objectives - To examine why couples in Lusaka were so reluctant to know their HIV status
• Design - Individual in-depth tape recorded interviews
• Subjects - Both partners of 89 co-habiting couples (178 husbands and wives)
• Setting - High density housing area in Lusaka, Zambia, where anonymous testing has shown that 25-35% of antenatal women are infected with HIV
• Results - The majority of those interviewed worried about HIV infection. They feared that they or their partner could be infected. Although many said that they had spoken about HIV with their partners many, particularly women, said this was difficult. Reasons for reluctance to undergo HIV testing, despite feeling at risk, were feeling unable to cope with a positive test, fear of stigma if found to be positive and lack of medical interventions for those with HIV. Few people mentioned the benefits of HIV testing for those who tested negative.
• Conclusions - HIV counselling and testing has been shown to be an important intervention in changing sexual behaviour and thus reducing HIV transmission in other settings. However, in Zambia if it is to have a major role, education of the benefits of knowing ones HIV status, particularly for the majority who will test seronegative, and support for those who test seropositive must be an integral part of any programme.

• Objectives - To find out why so many people who attended for c&t following invitation by a community mobiliser did not return to collect their HIV test results.
• Design - Individual in-depth interviews
• Subjects - A random sample of 50 people who had attended for c&t in but had not returned to collect their results
• HIV test results were given 1-2 weeks after the blood was taken for testing. Approximately half of the people who are invited for HIV c&t and agree to be tested subsequently fail to return to collect their test results. 89% of people who were "self-motivated" returned to collect their results.
• Setting - Chawama and Helen Kaunda HIV c&t centres in high density housing areas in Lusaka.
• Results - Some people who had been invited by an outreach worker said that they had had an HIV test because they wanted to please the outreach worker or the counsellor and then did not bother to return. Although many people gave theoretical reasons why it is a good idea to know ones HIV status they had changed their mind when they had returned home and discussed it with a friend or their sexual partner. Many people gave logistic or administrative reasons for not returning to collect their results, but this may reflect an underlying reluctance or ambivalence about knowing their status. Many people said that the counselling alone had influenced their behaviour. Some people said that they would have preferred to have received their test results on the same day.
• Conclusions - Many people in Lusaka who are invited for HIV c&t fail to collect their test results because they change their mind during the waiting period. This is very wasteful as the testing alone costs $US5. This wastage would be largely eliminated if same day testing was routine. However, if same day testing if implemented, the counsellor must ensure that the client is able to cope if the test is seropositive and has not been coerced into having a test.

• Objectives - To assess the supportive benefits of HIV/AIDS counselling for individuals with both seropositive and seronegative result, and to determine how those benefits are influenced by various aspects of counselling and testing (c&t) in Zambia.
• Design - Individual in-depth interviews, soon after post-test counselling (time 1: 1-2 weeks after receiving their HIV result), within the first six months after (time 2: 1-6 months) and in the second half of the year (time 3: 7-12 months) in order to show the effects of HIV c&t on coping and preventive behaviour soon after HIV c&t and over a period of time.
• Subjects - A random sample 377 people (both HIV seropositive and seronegative), who had received HIV c&t
• Setting - Three c&t centres in Lusaka
• Results:
  • There is continuing demand for HIV c&t in Lusaka. Despite Kara receiving intermittent funding there is and increasing demand for HIV c&t in Lusaka. However many people still do not want to know their HIV status.
  • Uptake of c&t increases if people are systematically invited by a mobiliser If people are invited by a community mobiliser more people wanted HIV testing.
  • People who are invited are more likely to be seronegative than those who self-present, which may enhance prevention of HIV transmission. Despite HIV being a very serious problem in Lusaka the MAJORITY of people tested for HIV at Kara test negative. Many assume that they will be seropositive, because of previous sexual partners, when they are in fact seronegative. Knowledge of their seronegative status is a great impetus to then remain negative. By offering HIV testing in the community we are thus able to help many people who test seronegative to stay negative. However it is also important to offer continuing support, both medical and emotional, for those who test seropositive.
  • Virtually everyone (95%) felt that counselling had been useful. Most people who have c&t at Kara centres, whether they test seropositive or seronegative, find it a useful experience.
  • Continuing counselling enables 95% of people to share their test results within 6 months. Although many people think that it will be difficult telling people that they have had a test, with the help of the counsellor most people were able to tell someone about their test and many people were able to bring their partners for testing.
  • Counselling does promote safer sex. If people know their HIV status they can then adopt "safer sex" practices. This means that HIV seronegative people can stay negative and HIV seropositive people can prevent transmission to other people.
  • Women still face considerable barriers because of gender inequalities in sexual decision making. Although men can use condoms it is often difficult for women to ask their husbands to do so - so if they test negative they may be at continuing risk from HIV infection from their husband, especially if he has other sexual partners.

• Dr Alwyn Mwiinga, Zambart Tuberculosis Preventive Therapy (TBPT): "Study Linking HIV counselling and testing to support services." This study has shown that TBPT reduces the incidence of TB in people with HIV by 50%. It is a cheap and popular intervention. It was also shown that recruiting people from Kara c&t sites was successful. Kara clients were much more likely to return for follow up and to take the TBPT as prescribed. It was proposed that this service should be routinely offered for people testing seropositive following voluntary c&t. Funding is being sought to establish whether the 6 month TBPT regime or a longer regime is more beneficial.
• Prof Alan Haworth, National Counselling Unit: "Experiences of HIV c&t from Kapiri Mposhi and Lusaka. Uptake of c&t following anonymous testing." When people who had taken part in the anonymous community HIV seroprevalence study were offered HIV c&t the uptake was very low. This finding highlight the continuing reluctance of many people to know their HIV status.
• Dr Connie Osborne, Department of Paediatrics: "UTH counselling parents of infected children." Paediatric index cases were used to identify mothers with HIV. They and their partners were offered HIV c&t and advise about further pregnancies.
• Dr Mudenda, Blood Bank: "Importance of counselling in recruiting blood donors." The blood bank reported a successful programme where seronegative donors were offered continuing support and counselling in order to provide a safe blood supply.
• Sister Shirley Mills: "Training counsellors." The Kara Counselling training programme has trained over 2000 counsellors in psycho-social counselling and HIV counselling skills. Special programmes have been developed for community carers, teachers, home-based care teams, and workplace groups.
• Cathy Poulter: "Counselling Dying Patients." Counselling symptomatic people is often a difficult and neglected area. Special training and skills and support of the counsellor and carer are needed for this.
• Rose Masozi & David Roth, Project San Francisco "Experience of couple counselling in Chiesa." PSF runs a research project which identifies couples who are discordant. They have found that this phenomena is poorly understood. They estimate that up to 25% of cohabiting couples are discordant and by identifying these couples they can reduce transmission to the uninfected partner.

The was general support for HIV c&t by the MoH and the expansion of the programme through the decentralised health care system. However until additional funds become available this seems an unrealistic goal. The donor representatives were also supportive of HIV c&t but had as yet not made definitive decisions about the structures of their HIV programmes and further meetings were suggested.

Issues Raised in the Meeting (consensus statements):

• Is HIV Counselling and Testing a priority for Zambia? Although the majority of the participants felt HIV c&t was an important intervention there was concern that if would draw resources away from other more basic services if it were to be available on a wider scale.
• Counselling and testing should be part of a package of continuous care with the provision of the appropriate tools for prevention. Many of the participants said that c&t should not be seen in isolation but must be part of a wider service, as is offered by Kara, with continuing support (emotional and medical) for those who test seropositive and their families and guidance and support for those who test seronegative so that they remain so.
• TB preventive therapy (TBPT) should be made available to those who require it. One service that can be offered to those who test seropositive in TBPT and it was felt that this was a realistic intervention. Counsellors/medical personnel should be able to offer this routinely and should discuss this with clients during post-test counselling sessions.
• Counselling alone is not sufficient but should include formation of support groups discussing issues such as "positive living". There was unanimous support of the benefit of "post test clubs". They have been shown by Kara to help those who test positive and negative. They help to reduce stigma and involve the community often with minimal external input. It was emphasised, however, that currently most support groups were male dominated and women's participation should be encouraged.
• Quality assurance of counselling offered to clients should be maintained through the supervision of counsellors.
• There is evidence that Voluntary Counselling and Testing is useful. Vc&t services should be provided with emphasis both on "Walk in" or "Mobilisation" strategies country wide. NGOs should be supported to provide these services by government. The contribution of PWAs to these services is important.
• Clinical research: Concern was raised about some HIV research projects in Zambia. The need for informed patient consent, and adequate counselling about he implications of research studies. The results should initially be fed back to the community rather than disseminated exclusively through specialist medical literature. It was also emphasised that studies using drug that were prohibitively expensive may have little relevance to Zambia. Furthermore careful ethical considerations had to be taken when studies were the only way that patients could have access to tests such as CD4 counts.
• No single approach to setting up counselling services is exclusively effective. There is a role for counselling services in different settings. Walk-in community, couple and youth counselling are complimentary. Counselling services provided through antenatal clinics may also be a useful strategy.
• Counselling training should help provide more people who feel comfortable with HIV issues. After 10 years of HIV prevention programmes in Zambia, HIV cannot be seen as a issue to be dealt with by specialists. It effects every aspect of life and thus people from every sector of society should be encouraged to have HIV counselling training.
• A focus should be made on provision of counselling services for adolescents who often do not have access to such services. HIV seroprevalence rates in the under 20s are significantly lower than in the 20-30 age group. Thus targeting this group is important if HIV c&t is to have maximum benefit in reducing HIV transmission.

Last updated October 11, 1997

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