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Understanding Couples Voluntary Counseling and Testing

Why is voluntary counseling and testing for couples an important process for recruiting women into vaccine trials?

Voluntary counseling and testing (VCT) is the process used by community-based clinics and trial sites to offer HIV testing, education, and counseling to individuals who want to know whether they are HIV infected or not. The VCT process involves learning about how HIV is transmitted and what behaviors put a person at risk for infection, in addition to the meaning and implications of the individual's test results.

There are several different types of VCT depending on whether the service is administered at a community clinic, as an initial screening for participation in an AIDS vaccine trial, or before joining a research study (see April Primer onUnderstanding Research Voluntary Counseling and Testing). There are also different types of VCT used to target specific populations. One involves testing and counseling couples that are married or living together, rather than individuals, and is therefore referred to as couples VCT (CVCT).

What is different about a CVCT session?

During a traditional VCT session a person is given information on what can put them at risk for HIV infection. In a couples session the counselor works with the couple to find out how their behaviors work together to influence their risk. This involves opening a dialogue between partners about their sexual activities and empowering them to communicate their shared risks, which can be complicated in countries where such discussion may be taboo. Nurse counselors encourage each person to take responsibility for their behaviors and inform them about ways the can limit their risk, such as using condoms. CVCT is a complex process because counselors are working with the needs and emotions of two people whose risks for HIV infection can involve others outside of their relationship.

A couple will go through the entire process together, including completing the consent documents (see June Primeron Understanding Informed Consent), pre-test counseling, HIV testing, and post-test counseling. The consent for participation in CVCT requires that the partners agree to receive their HIV test results together, but these results remain confidential outside of the couple.

Dependent on their test results, the nurse or counselor will work with the couple during the post-test counseling to help them make a plan for the future. In testing and counseling couples there are three scenarios: both partners are HIV infected, both are uninfected, or one is infected and the other is uninfected. This last case is what researchers refer to as a discordant couple. Counselors can work closely with discordant couples to create an atmosphere where the partners support each other, both through this process and in the future, while limiting the uninfected partner's risk of becoming HIV infected.

Working with couples rather than individuals has been shown to have many positive effects, including increased condom use and a lower rate of new HIV infections between partners.

Why is CVCT an important recruitment tool for AIDS vaccine trials?

To find out if an AIDS vaccine candidate is effective at blocking HIV transmission, researchers must administer the vaccine candidate to groups or cohorts of people who are at high risk of becoming infected with HIV. This requires testing the vaccine in countries or communities where there is a high prevalence of infection. In Africa, couples are at the highest risk for HIV infection and researchers estimate that between 60-70% of HIV transmission occurs within couples that are married or living together.

African couples are therefore an important cohort for evaluating the efficacy of AIDS vaccine candidates and CVCT is one way to enroll volunteers that are at high risk of HIV infection from heterosexual transmission. This may not be true on other continents like Asia, where HIV transmission is still mainly occurring in the more traditional high-risk groups such as sex workers or injection drug users.

How can CVCT be used to recruit women for vaccine trials?

CVCT is an important way for researchers to reach out to more women about accessing counseling and testing services as well as possibly joining a vaccine trial (see AIDS vaccine researchers find promise). In recent years the number of people utilizing VCT services in some areas of sub-Saharan Africa has increased dramatically, mainly because of new treatment programs that offer people life-saving drugs if they are found to be HIV infected. Despite being more vulnerable to infection, women remain underrepresented at many VCT sites.

Counseling and testing partners together can empower women to access VCT services, while avoiding discrimination or even possible violence from their husbands or communities. At some sites counselors will invite couples who have received CVCT to come for focus groups to see how they feel about possibly enrolling in a trial. Couples can learn about the vaccine candidate being tested and find out what it is like to volunteer for an AIDS vaccine trial.

One of the earliest centers to implement CVCT was a clinic in Kigali, Rwanda run by Projet San Francisco and Susan Allen, a researcher from Emory University who has established one of the largest couples counseling centers in Africa. This site started screening couples because women requested that their husbands also be tested. Of the original 1,500 women that were seen at the Kigali center, 1,000 were able to convince their husbands or partners to join them. The nurse counselors are now preparing for the site's first AIDS vaccine trial.