Couples HIV Testing and Counselling : examining uptake in Sub-Saharan Africa, and exploring the beliefs, intentions and experiences of couples in Ethiopia

Abstract

Couples HIV Testing and Counselling (CHTC) is recommended by the World Health Organisation to increase uptake of testing in Sub-Saharan Africa (SSA). There is limited evidence about whether people in heterosexual relationships consider CHTC to be a viable HIV testing option compared to other approaches, or the perceived risks and benefits of CHTC. This thesis examined the uptake, beliefs, intentions, and experiences associated with CHTC in SSA, and in Ethiopia specifically.

The thesis includes four studies in a mixed methods design: a systematic review and meta-analysis of CHTC uptake in SSA (n=14 peer-reviewed studies); a qualitative elicitation study (n=21 people in heterosexual relationships and n=11 key informants) of beliefs and intentions; a qualitative experience study (n=19 in-depth interviews) of people who had used CHTC; and the development and pilot of a survey informed by the elicitation study (n=100 individuals).

New empirical findings from this research include 1) a modest (24%) uptake of CHTC among heterosexual couples in SSA, with variability by country and population sub-groups; 2) that although CHTC was regarded as important to prevent HIV transmission, some participants stated they preferred to first ‘test alone, then together’ to avoid the perceived risks of being diagnosed with HIV in the presence of their partner — including accusations of infidelity and relationship break-up; 3) key reasons for undertaking CHTC included requests by third parties, such as religious institutions, before marriage, frequent sickness, as part of antenatal care, visa application, or mistrust between partners; 4) for some couples, consequences following an HIV-positive result included ongoing disputes, abuse, and relationship breakdown. Lastly, the elicitation study findings informed the development of a new survey tool for population-level use. Pilot psychometric testing found acceptable internal constancy, discriminant validity, and predictive ability of individuals’ behavioural intentions towards CHTC.

The collective findings in this thesis provide evidence that individuals are cautious of undertaking CHTC because of fears about confidentiality and potential risks to their relationships. Testing programs should monitor and assure adherence to the principles of confidentiality and voluntary testing. For individuals who decide to undertake CHTC, individual-based pre-test counselling is important to ensure informed decisions about HIV testing options.