Monday, December 13, 2010

Putting Testing to the Test: A Critical Evaluation of Voluntary Counseling and Testing in Sub-Saharan Africa – Jennifer Foth

Putting Testing to the Test: A Critical Evaluation of Voluntary Counseling and Testing in Sub-Saharan Africa – Jennifer Foth
In the fight against HIV/AIDS in sub-Saharan Africa, HIV voluntary counseling and testing (VCT) has been touted as an effective individual-level intervention. The primary benefit of VCT (which consists of pre-counseling, testing, and post-counseling) lies in the information that is provided before and after testing, which is believed to enhance individual HIV risk reduction knowledge, attitudes, and behaviors (1). For those receiving positive test results, VCT can serve as a gateway to clinical care and support services to reduce the probability of transmitting HIV to others (2). For those who test negative, VCT provides information on safer sex behavior and how to prevent future infection. However, despite the benefits offered by VCT, its utilization among high-risk populations in sub-Saharan Africa remains discouragingly low. Recent estimates based on surveys in 12 high-burden countries in sub-Saharan Africa indicate that only 12% of men and 10% of women have been tested for HIV and received the results (3). Demographic and health surveys in several African countries have also shown that, among those who do not know their HIV status, over two-thirds would like to get tested. Yet, the proportion of those who report actually having been tested remains below 15% in some areas (4).
This discrepancy between intention and actual behavior highlights the fundamental weakness of the theoretical underpinnings of VCT. The support for VCT as an important entry point for HIV risk communication, treatment, and care has overshadowed the need to assess its true impact as a behavioral risk reduction strategy (1). In determining whether testing opens the gate to treatment and promotes behavior change, the extent to which fears of VCT and the barriers to access are overcome must be evaluated. In this paper, I will provide a critique of the theoretical foundation of VCT using alternative theories of social and behavioral change to highlight the specific social and structural factors that discourage VCT uptake in sub-Saharan Africa. I will then incorporate these factors and alternative theories into my proposal for a new, more comprehensive framework for VCT provision in sub-Saharan Africa.
The Theoretical Foundation of VCT
Voluntary Counseling and Testing (VCT) is an HIV intervention that includes both voluntary pre- and post-test counseling and voluntary HIV testing. VCT provides individuals with the opportunity to confidentially explore and understand their HIV risks, learn their HIV status and link to care and support services. The expected effect of VCT is to lower HIV transmission through reduction in high-risk sexual behaviour, improved medical care, and improved access to care and support services for both HIV-positive and HIV-negative persons (5).
VCT is offered in a variety of settings and by many institutions, including non-governmental organizations (NGOs), community-based organizations, mission and government hospitals, and health centers. Integrated VCT is usually incorporated into existing healthcare settings, such as sexually transmitted infection (STI) and tuberculosis clinics, family planning and maternal health services. Stand-alone programs, typically operated by non-governmental organizations, offer VCT away from health services but with frequent referrals to care and support services (6). Mobile VCT entails the provision of testing services by mobile teams from a van equipped with HIV-testing facilities. Mobile teams will often set up temporary sites where they offer services to the general population, defined groups such as a church congregation, or to hard-to-reach groups such as injection drug users and sex workers. Under the home-based VCT approach, counseling and testing services are provided door-to-door in client homes, often by community health workers. This approach enables counselors to both test and discuss HIV risk and prevention on a larger scale, one family at a time (6).
All of the aforementioned VCT provision methods fall under the category of client-initiated VCT, indicating that those who wish to get tested must take the initiative and seek out the services themselves. Each method therefore requires individual recognition of the risk and severity of HIV, followed by the decision to get tested. Client-initiated VCT is thus founded firmly upon the Health Belief Model (HBM), a model of health behavior change originally developed to explain the uptake of health services (7). The HBM stipulates that health-related behavior depends on four key beliefs about perceptions regarding the condition: susceptibility to the condition, its severity, the benefits of adopting a new behavior and the barriers to implementing that behavior (8). In deciding whether to utilize VCT, individuals must believe 1) that they are susceptible to contracting HIV and 2) that the consequences will be severe if they do contract the disease. The benefits of getting tested and knowing one’s HIV status are then weighed against any barriers to VCT utilization that might exist. Assuming the benefits outweigh the costs, the HBM predicts that individuals will decide to – and eventually will – get tested.
Studies have shown, however, that intent seldom leads to behavior when it comes to the uptake of VCT within sub-Saharan African populations. The architects of VCT programs have failed to consider “the role of demographic, socio-psychological and structural variables… [that serve] to condition both individual perceptions and the perceived benefits of preventive actions” (7). Disparities in risk perception, fear of social stigma, concerns regarding the confidentiality of one’s status, and issues of accessibility all directly challenge the rationale for the HBM as the theoretical basis for VCT service provision (9).
Disparities in Risk Perception
One of the primary underlying assumptions of the HBM as it relates to VCT is that populations in sub-Saharan Africa are aware of the risks posed by HIV/AIDS, and that this awareness is sufficient to increase individual perceptions of susceptibility and disease severity. Education and awareness campaigns, detailing the high rates of HIV infection and encouraging the adoption of risk reduction strategies (i.e. abstinence, condoms), abound in sub-Saharan Africa. VCT providers have even developed their own media campaigns to increase awareness of HIV risk and promote testing services. Unfortunately, as the statistics on VCT utilization indicate (see Introduction), these educational campaigns do not appear to be achieving the desired results. In reality, the content of these campaigns often works to their own disadvantage. VCT campaigns frequently employ images of middle-class couples and individuals to convey their message. Unfortunately, these images do not always resonate with all segments of the population. As one woman notes, ‘‘In rural areas the billboards should not show pictures of rich people from town. Where is the tomato seller in the market who says to her neighbor, ‘Please mind my stall. I want to fetch my husband and we go for VCT?’’’Others have expressed their frustration with ‘‘mass media depicting couples counseling as only for the few who have big dreams, laptops and MAs... How many of our women have that?” (10).
The disconnect between the individuals featured in, and the individuals exposed to, VCT campaigns may therefore be compromising their effectiveness. In his article entitled “Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance”, Paul J. Silvia argues that social influences, including education and awareness campaigns, “can threaten people’s freedom to decide autonomously, to form their own opinions, to hold various attitudes (or none at all), and to do what they feel free to do” (11). Campaigns extolling the dangers of HIV, and compelling individuals to use VCT and other risk-reduction methods, pose an inherent threat to individual autonomy, particularly as it relates to sexual decision-making. While such campaigns may create an initial positive force to comply, they ultimately create a stronger negative impulse to react (11). However, reactance can be minimized when messages that threaten autonomy are presented by people with a high degree of similarity to the target audience. As Silvia notes:
An individual is likely to feel that persons with status, values, interests, and needs similar to his own see things as he does and judge them from the same point of view. Because of this, their assertions about matters of which the individual is ignorant…will tend to carry special credibility. (11)

The lack of similarity between at-risk populations and the individuals featured in VCT campaigns may thus be inducing psychological reactance and compromising their goal of increasing perceptions of HIV susceptibility and disease severity.
In many sub-Saharan African countries, a gender gap in HIV/AIDS risk perception serves to further undermine the objectives of VCT. A number of studies have shown that, overall, men are less likely than women to perceive themselves as at risk of contracting HIV/AIDS (10), an important finding given the asymmetrical power dynamics that typically characterize male-female relationships in sub-Saharan Africa. As described in the Theory of Gender and Power, relationships between men and women are characterized by three major structures: the sexual division of labor, the sexual division of power, and the structure of affective and social exposures (12). Power in this context is conceptualized as having the power to act or change, or having power over others. The inequities resulting from the sexual division of power are often manifested in behavioral risk factors for HIV. As the power inequity increases in favor of men, women’s sexual choices and behavior may be constrained (12). Women may thus feel they do not have the self-efficacy (or confidence in their ability to effect change) necessary to negotiate VCT utilization. As one Kenyan woman explained: ‘‘The woman usually brings the message of VCT home. Like in my case. Then I’ll keep asking let’s go for a test but we will never go unless he thinks we need to. Once he makes up his mind we go…’’(10). In fact, most married females in the same Kenyan study reported that they would have to obtain permission from their spouses before making any type of sexual decisions such as when to have sex, use a condom or get tested for HIV, choices which are generally perceived to be within the realm of male decision-making (10). The same study also showed that, while taking condoms home from a VCT session was viewed as acceptable for male clients, for women it was quite different, as ‘‘most women would risk having unprotected sex rather than offend their partners by taking home condoms–especially the married ones since it could seem as though they do not trust them [their husbands]’’ (10). Failure to recognize and address these gendered power dynamics will inevitably limit the reach and impact of VCT services on female populations within sub-Saharan Africa.
VCT uptake in sub-Saharan Africa is also heavily influenced by social norms and attitudes, most notably the stigmatization of persons living with HIV/AIDS (PLHAs). In ancient Greece, the term ‘stigma’ referred to a sign, mark, cut or burned into the body that designated the bearer as a person who was morally defective and to be avoided (13). Today, according to Erving Goffman’s theory of social stigma, a stigmatized individual is:
[One] whose social identity, or membership in some social category, calls into question his or her full humanity; the person is devalued, spoiled or flawed in the eyes of others. Generally, there is nothing objectively wrong with the person, it is those others who supply the label and attach a negative meaning to whatever characteristic the individual possesses. (13)

Stigma is most frequently attached to a disease whose cause is perceived to be the bearer’s responsibility. Consequently, because the primary routes of HIV/AIDS transmission are behaviors that are widely considered to be voluntary and immoral (homosexuality, promiscuity, sex prostitutes, intravenous drug use, etc.), PLHAs are seen as responsible for their condition (14). In many sub-Saharan African countries, fear of HIV stigma is cited as a main cause of reluctance to utilize VCT, since those who test positive may face rejection from their family and community.
In our society, people are rejected when they are infected with HIV. . . When someone is rejected by his entourage because he is ill, he will find himself confronted with two illnesses instead of one – because exclusion is also an illness. [Bamako, man, 28 yrs old] (15)

Regardless of one’s test results, the mere act of entering a VCT site may be enough to incur social stigma. Given the very public face of stand-along VCT centers, an association is often automatically made between visiting testing centers and being HIV positive. Such associations can decrease motivation to seek out VCT among individuals who do not want to “give people the wrong idea” (10). Given the choice, many would rather not know their HIV status than risk being labeled and ostracized if they happen to test positive.
HIV/AIDS related stigmatization manifests itself in numerous contexts, not just within the community (13). In fact, fear of stigmatization from VCT counselors themselves is frequently cited as a significant deterrent to VCT utilization. Counselors often live within the community where the VCT center is located and are embedded in the local social networks. Thus, for those interested in being tested, VCT counselors symbolize the incursion of public, social stigma into what should be a very private experience. As a result, confidentiality and distrust of VCT personnel is often a major concern for those considering VCT. As one man from Malawi explained:
[I]f I can be tested at Mhojo Health Centre, VCT counselors there know me and if that counselor at the VCT [centre] finds me with the virus then he can start spreading the messages to friends of mine, and if I know about that then it becomes very bad to my life...(16)

The location of VCT centers may further spark concerns over stigmatization and confidentiality among those interested in getting tested. As previously noted, VCT is often provided at stand-alone sites or by mobile VCT teams in public venues such as churches or community centers. These means of provision make it very difficult for individuals to access VCT without being seen, and potentially stigmatized, by other community members. Even integrated VCT services offered in clinical settings may not alleviate confidentiality concerns, as they are often located in separate wings of the building. The separation of VCT from other medical services can quickly reveal the true purpose of an individual’s visit to outside observers who are aware that “there is a separate room for HIV testing and…see you coming into the room with a smiling face, but when you are coming out they find you with a disappointed face, then they just conclude that you have been found HIV positive,” (4).
The effect of HIV/AIDS stigmatization on VCT uptake can be explained in terms of Social Identity Theory, first developed by Henri Tajfel in the 1980s. Social Identity Theory suggests that group memberships form a fundamental part of people’s identities and that people are motivated to establish and maintain their positive social identities (13). Fear of HIV/AIDS stigmatization thus arises out of an individual’s need to protect their identity as health and non-deviant members of society. Unfortunately, fear of HIV/AIDS stigma and concerns over testing confidentiality have lead to an impasse regarding VCT. Given the high levels of HIV/AIDS stigma in some communities, VCT counselors feel ethically bound to warn clients that testing positive could expose them to HIV/AIDS stigma. This warning only reinforces the fear of stigmatization within the community, further decreasing VCT utilization (13).
Barriers to VCT Access
Finally, the structural barriers of cost and distance serve as prohibitive factors to accessing VCT services, particularly in rural areas. High-quality VCT services tend to be located in urban areas that enable VCT providers to reach a greater number of at-risk individuals and tap into a larger pool of trained health professionals. As a result, individuals in rural areas where mobile VCT is not provided must travel great distances to access VCT, often at great cost. Moreover, many VCT centers require clients to visit at least twice – once to conduct pre-counseling and get tested, and once to receive their test results and conduct post-test counseling (17).
Implicit in the Health Belief Model, the theoretical foundation of client-initiated VCT, is the assumption that an analysis of the costs and benefits of testing will lead to the intention and behavior of getting tested. In reality, the high monetary and opportunity costs associated with accessing VCT services more often than not outweigh the benefits of testing for rural or low-income populations. The impact of these costs on individual behavior are captured in the Theory of Self-Efficacy, according to which “two types of expectancies exert powerful influences on behavior: outcome expectancy, which is the conviction that certain behaviors will lead to certain outcomes; and self-efficacy expectancy, which is the conviction that one can successfully execute the behavior required to produce the outcomes” (18). For the over 500 million people living in rural sub-Saharan Africa (19), the financial and structural barriers alone are enough to reduce individual self-efficacy and prevent individuals from seeking access to VCT. In the absence of more pressing reasons to travel to urban areas, individuals will not view the benefits of VCT as being worth the monetary cost of transportation and the opportunity cost incurred by hours spent traveling and waiting to be seen by a VCT counselor (4).
MHC-VCT: A New VCT Paradigm
When faced with significant barriers to access, potential stigmatization and uncertainties regarding testing confidentiality, simply weighing costs and benefits is not enough. The Health Belief Model does not account for these important social and structural factors that so profoundly complicate the issue of accessing VCT. To increase the scope and impact of VCT on increasing HIV risk perception and reducing risk behavior, the theoretical foundations of VCT must be expanded to incorporate these social and structural factors into the VCT provision framework.
First, VCT providers must use the Theory of Psychological Reactance to their advantage, at both the community and interpersonal level, to narrow the gap in risk perception between urban and rural populations. In his study on psychological reactance, Silvia showed that people agree more with messages presented by individuals who shared similar values and beliefs. To mitigate the inherent threat to personal and sexual freedom posed by VCT awareness campaigns, individuals with greater similarity to the target population should be featured in mass communication materials such as billboards, pamphlets, TV and radio advertisements. Individual responses to health messages tend to be “influenced by…background characteristics (such as gender or ethnic group), [and] attitudes,” (3). VCT materials should thus be adapted to the social, cultural and regional contexts in which they are being distributed by prominently featuring members of a particular ethnic group, religion or profession.
On a more personal level, VCT service providers should incorporate participatory meet-and-greet sessions with PLHAs into their education and outreach campaigns. Rather than presenting information on HIV/AIDS risk in a one-directional manner, VCT providers should offer “direct and personal contact with those suffering from AIDS and the chance to exchange opinions with them and to ask questions,” (15). Research and theories such as Fuzzy Trace Theory suggest that, for a change in perception to occur, individuals need to translate statistics and abstract notions of risk into more personal, tangible terms (3, 20). Research further suggests that the mere experience of knowing someone with HIV/AIDS can positively predict individual behavior change (15). Engaging PLAHs in the educational component of VCT will provide clients with the opportunity to see the similarities that exist between themselves and PLHAs, and lead to a greater internalization of risk and perceived susceptibility to HIV.
My second recommendation would be for VCT service providers to focus their efforts and resources on the provision of all-in-one mobile, home-based, couples VCT (hereafter referred to as MHC-VCT). MHC-VCT combines the three VCT sub-groups which have repeatedly been shown to be the most effective in promoting behavior change (6). By enabling couples to negotiate changes in sexual behavior together, the “couples” element of MHC-VCT works to reduce the asymmetries in the sexual distribution of power between men and women, which are often deeply ingrained in the social and cultural fabric. By providing MHC-VCT, counselors can foster an open and honest discussion, in a familiar environment, about the sensitive topics of HIV risk behavior and risk mitigation. The “home-based” element will furthermore increase female participation in traditionally male-dominated societies, in which the husband is the primary decision-maker (17). MHC-VCT brings the services to the women themselves, rather than requiring them to obtain permission from their husbands or forgo their domestic responsibilities in order to access VCT services. The result is greater outreach and impact on both sexes, as evidenced by one Ugandan study, which found that home-based VCT “increased acceptance of testing from 10% to 46% and eliminated differences in acceptance between women and men” (3).
Whenever possible, MHC-VCT visits should be conducted by both a male and female counselor. In many traditional societies, it is not considered acceptable for men to discuss issues relating to sexual behavior with women (and vice versa), even in a clinical setting. Thus, it may be necessary in some contexts for counselors and clients to be matched by gender in order to reduce psychological reactance against HIV risk behavior prevention messages. To assuage concerns over confidentiality, MHC-VCT visits should also be conducted, where feasible, by non-resident counselors. As one Ugandan man noted, the benefit of being tested by a non-resident counselor lies in the fact that “[he] can’t reveal the secret because he doesn’t know anyone in the villages and he will not have time to reveal because we expect him after testing to go somewhere else where there is no one who is familiar with me,” (17). When the employment of non-resident counselors is not fiscally or logistically possible, the importance of confidentiality should be reinforced by intensive counselor training and by providing test results verbally, so as not to leave documentation of HIV status accessible to third parties. These measures will increase client trust in counselors and diminish fears of potential stigmatization resulting from leaked test results.
At the same time, MHC-VCT can combat the stigmatization so often associated with VCT utilization. Providing VCT in a private setting eliminates the stigmatization associated with being seen at, or entering, a public VCT site. Stigmatization of those living with HIV/AIDS, and those who get tested, will be further reduced by the interaction between clients and PLHAs incorporated into MHC-VCT. While one could argue that high levels of HIV/AIDS stigmatization in certain areas might place PLHAs participating in MHC-VCT at greater risk of being ostracized or persecuted (6), there are theories that would contradict that argument. One such theory, proposed by Pryor et al., is the “two-factor” theory of stigma, which suggests that:
When confronted with PLHAs, people's initial reaction is characterised by a relatively automatic negative affect [sic]. Then, given time, cognitive resources, and motivation, this initial negative response can be adjusted. The result is that this adjustment will often result in a more moderate or less negative reaction to the stigmatised person. (13)

The improvements proposed above will make those “cognitive resources” more available to a greater portion of the population. Over time, the elements of the MHC-VCT provision framework can combat HIV-related stigmatization, eventually producing a fundamental shift in the social norms surrounding HIV testing, counseling and the disease itself.
It is clear that the practical barriers of distance and cost, combined with social factors related to the perception of risk and fear of stigmatization, impede VCT utilization in sub-Saharan Africa. These barriers can be largely overcome, however, by reevaluating the theoretical basis of VCT provision and incorporating alternative theories of social and behavioral change. In so doing, the components of MHC-VCT proposed above can help to narrow the gender gap in the distribution of sexual power, thereby decreasing barriers to access, increasing outreach, and maximizing the impact on both male and female perceptions of HIV risk. Unfortunately, human and financial resource constraints may preclude many countries in sub-Saharan Africa from adopting all or most of the MHC-VCT recommendations. To realize the full benefits of counseling and testing, governments, NGOs, donors and the public health community must be willing to challenge the traditional thinking behind VCT provision and focus their resources on interventions that attack the underlying social and structural barriers to access.


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