The Feasibility of Community-Based VCT in Zimbabwe Gertrude Khumalo-Sakutukwa and Steve Morin AIDS Policy Research Center AIDS Research Institute University of California, San Francisco

Background F Most HIV infections are in sub-Saharan Africa, yet only a small fraction of Africans know their HIV status. F Voluntary HIV Counseling and Testing (VCT) is an effective method of promoting behavior change, but utilization of VCT is still low in African communities with a high prevalence of HIV.

Zimbabwe Harare ~25% of sexually active Zimbabwean adults are infected with HIV, yet only a small percentage know their HIV status

Access to VCT F 10% know their HIV status F Limited VCT services F VCT uptake low F Diagnostic HIV testing in hospitals & private sector F PMTCT-VCT (mums & babies)-national F 14 VCT sites - PSI/USAID/Zim-MOH

Community-Based VCT F Intervention has three major strategies: v to make VCT more available in community settings v to engage the community through outreach; and v to provide post-test support. F These three strategies are designed to change community norms and reduce risk for HIV infection among all community members, irrespective of whether they participated directly in the intervention.

Aim 1: Acceptability F Aim: To assess acceptability of Mobile VCT (MVCT) in two communities F Method: A mobile caravan provided free, anonymous VCT in 12 market areas, visiting the sites on a rotating basis for one week, using two rapid HIV tests (Unigold and Determine) F Sample: 1101 adults who completed VCT at the community-based sites

The road to market in Epworth

Setting up the caravan for VCT at the Solani Marketplace in Epworth

“Plan for Tomorrow -- Get HIV Tested Today”

Results F 99% of participants chose to receive their results on the same day. F No adverse outcomes (acts of discrimination or physical violence) were observed or reported. F 32% of testers were under 26, and 70% were under 31. More men (58%) than women (42%) tested. F HIV prevalence was 29%, higher than the figure reported among clients of fixed-site testing centers in Harare of approximately 17%.

Aim 2: Predictors of Testing F Aim: To assess predictors of mobile testing F Method: Questionnaires were administered in face-to-face interviews regarding knowledge of HIV, use of Mobile VCT, risk behaviors and demographics F Sample: 483 testers at the Mobile VCT sites and 332 individuals who did not access VCT at the same sites (non-testers)

Women deciding whether to test On the scene with mobile VCT …

Reasons for No Prior Testing N/Total%Yes Hours are not convenient 89/ % Location is not convenient 72/ % Cost is too high 28/3508.0% Concern about confidentiality 7/3502.0% Don’t trust the result will be correct 1/3450.3% Embarrassed to be seen at testing center 0/3430%

Predictors of HIV Testing F Being at increased risk of HIV infection, i.e., reporting “feel at increased risk” (p<.001); F reporting one or more STIs (p,.001); and F not using condoms in last 3 months (p<.01)

Aim 3: Views About Testing F Aim: To explore beneficial or adverse outcomes of Mobile VCT F Method: In-depth interviews with testers and non- testers to determine knowledge of HIV, factors determining the use of Mobile VCT and preferences regarding programmatic options F Sample: 30 testers at the Mobile VCT sites and 29 individuals declining VCT at the same sites (non- testers)

Counselors and outreach worker ready for action

Motivations to test F Motivations to test included vconcern about physical symptoms of illness vthe death or illness of a family member or friend v perceived risk of HIV infection

Barriers to Testing F Structural barriers to testing included expense and travel time F Psychological barriers included fear that a positive result would lead to emotional distress and physical symptoms such as weight loss or illness F Testers reported that mobile VCT removed structural barriers, allowing individuals to confront psychological barriers

Overcoming Barriers F Testers reported that discussions with mobile VCT staff and outreach workers helped them overcome psychological barriers F 28 of 29 testers reported having recommended VCT to family members or friends F Stigma was not cited as a primary reason for declining testing by any non-testers F Both testers and non-testers believed mobile VCT was beneficial to their communities

Conclusions F Barriers to HIV testing in Sub-Saharan Africa are often logistical and can be overcome through community-based strategies. F Same day testing in a community setting is acceptable and attracts individuals at increased behavioral risk of HIV infection. F Mobile VCT removed structural barriers, allowing individuals to confront psychological barriers.

Acknowledgements F Office of AIDS Research (OAR) and National Institute of Mental Health (NIMH) F Zimbabwe Investigators: Janell Routh, Katherine Fritz, Tinofa Mutevedzi, Taurai Vaki and Owen Mapfumo F MVCT Team and support staff at UZ-UCSF Research Collaborative in Zimbabwe F Epworth Community Advisory Board and Epworth Local Board F UCSF AIDS Research Institute Innovative Grant Program F UCSF Investigators: Agnes Fiamma, Edwin Charlebois, Marisa McLaughlin, & Richard Vezina

Project Accept F Phase III randomized controlled trial to determine the efficacy of a community-level behavioral intervention in reducing HIV seroincidence. F Randomizing 46 Communities v8 in rural Zimbabwe v8 in rural Tanzania v8 in Soweto, South Africa v8 in Vulindlela, KwaZulu Natal, South Africa v14 in Northern Thailand

Mashonaland East Province

Gertrude Khumalo-Sakutukwa gkhumalo- Tel: