Studies on HIV voluntary counseling and testing in developing countries show positive results

By Jeff Sheehy

Results from two studies proving the efficacy and cost-effectiveness of
providing voluntary counseling and testing for HIV-1 in developing countries
are reported in the new issue (July 8) of the British medical journal The

The studies were designed to answer specific policy questions, according to
Thomas J. Coates, PhD, director of the AIDS Research Institute at the
University of California San Francisco and one of the lead investigators.

“Should voluntary counseling and testing be offered in sub-Saharan Africa
where there is little hope of antiretroviral treatments for individuals who
test positive for HIV?  And, does it work and is it cost-effective in these
settings?  The answer to both questions is an emphatic yes,” he said.

The efficacy study, headed by Coates, enrolled 3,120 individuals and 586
couples in Nairobi, Kenya; Dar es Salaam, Tanzania; and Port-of-Spain,

The cost-effectiveness study was led by Michael Sweat, PhD, from the Johns
Hopkins University School of Hygiene and Public Health, with Coates as a
co-investigator.  This study modeled outcomes based on behavioral and
biological results from the efficacy research in Nairobi and Dar es Salaam.
Cost-effectiveness was estimated for a hypothetical cohort of 10,000 persons.

“Voluntary counseling and testing saves money, as the cost of the intervention
is far less than the cost of even minimal HIV treatment, not to mention the
cost of orphans, lost productivity, loss of skilled labor, tuberculosis, and
the enormous impact on individuals and communities,” Sweat said.

According to Coates, the efficacy study is the only randomized controlled study
to look at the impact of HIV voluntary counseling and testing in developing
countries and is also the only randomized controlled study in the world to look
at the impact of VCT on couples.

In this research project, individual and couple participants were randomly
assigned to receive either voluntary counseling and testing (VCT) or basic
health information (HI).  Couples received results separately and then were
encouraged to share their results in the presence of a counselor.  All
participants received unlimited condoms. 

Follow-up sessions with participants were scheduled at about 7 months and about
13 months after test results were received.  At the first follow-up, the HIV
participants were offered VCT, and all VCT participants were offered
retesting.  Sexually transmitted diseases were diagnosed and treated at the
first follow-up.  The retention rate at the first follow-up was 82 percent for
individuals and 85 percent for couples.  For the second follow-up, the rate was
70 percent for individuals and 76 percent for couples.

Profound behavior changes between the two groups were observed at the first
follow-up, according to Coates.  Individual men assigned to VCT reported
reduced unprotected intercourse with non-primary partners by 35 percent, 
compared to a 13 percent decrease by the men assigned HI.  Women in the VCT
group reported a 38 percent reduction in unprotected intercourse versus a 17
percent reduction by women assigned HI.  Individuals diagnosed with HIV-1 were
more likely than uninfected individuals to reduce unprotected intercourse with
primary partners.
Study results also showed that couples assigned VCT reduced unprotected sex
with their partner significantly more than couples assigned HI.  Couples in
which one or both members were diagnosed with HIV-1 were more likely to reduce
unprotected intercourse with each other than couples in which both members were
uninfected.  In addition, at the first follow-up, when the control group
receiving HI was offered VCT, 90 percent wanted to be tested. 

The behavioral changes noted in the original VCT group were maintained at the
second follow-up, according to study findings.  Participants from the control
group who elected to receive VCT replicated the behavioral changes of those
initially receiving VCT.

The second study found VCT to be a very cost-effective intervention in urban
East African settings.  “VCT is feasible in developing country settings using
local systems and personnel.  It only costs about $27 per person to provide
high quality VCT in East Africa,” Sweat said.

The cost analysis was based on client infection status, sex, and whether VCT
was received as an individual or as a couple.  VCT was estimated to avert 1,104
HIV-1 infections in Kenya and 895 HIV-1 infections in Tanzania during the year
after receiving VCT.  The cost per averted infection in Kenya was $249 and $346
in Tanzania.  The cost per disability-adjusted life-years (DALY) saved in Kenya
was $12.77 and $17.78 in Tanzania.

According to Sweat, the results are comparable to other HIV interventions. 
“For approximately every $15 spent on VCT, one DALY is saved.  This compares to
a cost of $10 per DALY from enhanced sexually transmitted disease treatment and
$8 from universal provision of Nevirapine to pregnant women.  In addition,
targeting VCT to persons likely to be infected with HIV and couples
significantly enhances cost-effectiveness, ” he said.
Increasing the proportion of couples to 70 percent reduces the cost per DALY
to $10.71 in Kenya and $13.39 in Tanzania, according to the analysis. 
Targeting a population with HIV-1 prevalence of 45 percent reduces the cost per
DALY to $8.36 in Kenya and $11.74 in Tanzania.

Sweat cautioned against simply providing testing.  “While personnel is the
major cost with the HIV test itself only costing about $4.00, counseling is an
important aspect of the intervention. A member of our group, Dr. Gloria Sangiwa
from Muhimbili University said to me, ‘People come in for the test, but they
value the counseling’.”

The studies were supported by grants from AIDSCAP/Family Health International,
the World Health Organization, the United Nations Program on AIDS, and the
National Institute of Mental Health.

Study co-authors are Olga A. Grinstead, PhD, MPH; Steve Gregorich PhD; David
Heilbron, PhD; William Wolf; Julius Schachter, MD; Peter Scheirer; and Ariane
van der Straten, PhD, MPH, all of the UCSF Center For AIDS Prevention Studies;
Munkolekole Claudes Kamenga, MD; Gina Dalabetta, MD, and Isabelle de Zoysa, MD,
all of AIDSCAP/Family Health International;  Sam Kalibala, MD; Monica Ruiz,
PhD; David Miller, PhD, and Ben Nkowane, MD, all of UNAIDS; Eric Van Praag, MD,
MPH, and Kevin O’Reilly, PhD, of the World Health Organization; Gloria
Sangiwa, MD; Margaret Hogan, PhD; Davis Mwakagile, MD, and Japhet Killewo, MD,
MPH, all of Muhimbili University College of Health Sciences; Don Balmer, PhD;
Francis Kihuho; Steve Moses, MD, and Francis Plummer, MD, all of the Kenya
Association of Professional Counselors and the University of Calgary; and Colin
Furlonge, MD, of Queen’s Park Counseling Center, Trinidad & Tobago.