Male partner voluntary counselling and testing associated with the antenatal services in Kinshasa, Democratic Republic of Congo: a randomized controlled trial

Low male participation in voluntary counselling and testing (VCT) services at antenatal clinics (ANCs) represents a lost HIV-prevention opportunity. A three-arm randomized controlled trial (RCT) was conducted that offered VCT at a neighbourhood health centre, bar or church to the male partners of pregnant women attending a maternity unit in Kinshasa, Democratic Republic of Congo (DRC). The primary outcome was the proportion of male participation at VCT; secondary outcomes were uptake of couple counselling and determinants of male and couple participation. From a total of 2706 women included in the study, 591 male partners (22%) attended one of the three venues. Male participation was significantly higher in bars (26%, P < 0.001), and higher but not statistically significant in church-based VCT (21%, P = 0.163) compared with health centre VCT (18%). Male participation in VCT associated with ANCs was higher in non-health service settings, particularly in bars. A combination of different strategies rather than single targeted interventions will be needed to increase VCT uptake in male partners of women seeking VCT at ANCs.     

Voluntary counselling and testing: uptake, impact on sexual behaviour, and HIV incidence in a rural Zimbabwean cohort

OBJECTIVES: To examine the determinants of uptake of voluntary counselling and testing (VCT) services, to assess changes in sexual risk behaviour following VCT, and to compare HIV incidence amongst testers and non-testers. METHODS: Prospective population-based cohort study of adult men and women in the Manicaland province of eastern Zimbabwe. Demographic, socioeconomic, sexual behaviour and VCT utilization data were collected at baseline (1998-2000) and follow-up (3 years later). HIV status was determined by HIV-1 antibody detection. In addition to services provided by the government and non-governmental organizations, a mobile VCT clinic was available at study sites. RESULTS: Lifetime uptake of VCT increased from under 6% to 11% at follow-up. Age, increasing education and knowledge of HIV were associated with VCT uptake. Women who took a test were more likely to be HIV positive and to have greater HIV knowledge and fewer total lifetime partners. After controlling for demographic characteristics, sexual behaviour was not independently associated with VCT uptake. Women who tested positive reported increased consistent condom use in their regular partnerships. However, individuals who tested negative were more likely to adopt more risky behaviours in terms of numbers of partnerships in the last month, the last year and in concurrent partnerships. HIV incidence during follow-up did not differ between testers and non-testers. CONCLUSION: Motivation for VCT uptake was driven by knowledge and education rather than sexual risk. Increased sexual risk following receipt of a negative result may be a serious unintended consequence of VCT. It should be minimized with appropriate pre- and post-test counselling.     

Patterns of Self-reported Behaviour Change Associated with Receiving Voluntary Counselling and Testing in a Longitudinal Study from Manicaland, Zimbabwe

Voluntary counselling and testing (VCT) is promoted as a potential HIV prevention measure. We describe trends in uptake of VCT for HIV, and patterns of subsequent behaviour change associated with receiving VCT in a population-based open cohort in Manicaland, Zimbabwe. The relationship between receipt of VCT and subsequent reported behaviour was analysed using generalized linear models with random effects. At the third survey, 8.6% of participants (1,079/12,533), had previously received VCT. Women who received VCT, both those positive and negative, reduced their reported number of new partners. Among those testing positive, this risk reduction was enhanced with time since testing. Among men, no behavioural risk reduction associated with VCT was observed. Significant increases in consistent condom use, with regular or non-regular partners, following VCT, were not observed. This study suggests that, among women, particularly those who are infected, behavioural risk reduction does occur following VCT.     

Women's barriers to HIV-1 testing and disclosure: challenges for HIV-1 voluntary counselling and testing

In view of the ever-increasing HIV/AIDS epidemic in sub-Saharan Africa, the expansion of HIV-1 voluntary counselling and testing (VCT) as an integral part of prevention strategies and medical research is both a reality and an urgent need. As the availability of HIV-1 VCT grows two limitations need to be addressed, namely: low rates of HIV-1 serostatus disclosure to sexual partners and negative outcomes of serostatus disclosure. Results from a study among men, women and couples at an HIV-1 VCT clinic in Dar es Salaam, Tanzania are presented. The individual, relational and environmental factors that influence the decision to test for HIV-1 and to share test results with partners are described. The most salient barriers to HIV-1 testing and serostatus disclosure described by women include fear of partners' reaction, decision-making and communication patterns between partners, and partners' attitudes towards HIV-1 testing. Perception of personal risk for HIV-1 is the major factor driving women to overcome barriers to HIV-1 testing. The implications of findings for the promotion of HIV-1 VCT programmes, the implementation of partner notification policies and the development of post-test support services are discussed.     

Using prevalence data from the programme for the prevention of mother-to-child-transmission for HIV-1 surveillance in North Uganda

OBJECTIVES: To validate the use of data from a programme for the prevention of mother-to-child transmission (PMTCT) in estimating HIV-1 prevalence in North Uganda. METHODS: The study was conducted at St. Mary's Hospital Lacor. We compared the estimated prevalence for 3580 attendees at the antenatal clinic who were selected for anonymous surveillance to that for 6785 pregnant women who agreed to undergo voluntary counselling and testing (VCT) for enrolment in the PMTCT programme. Log-binomial regression models were used to identify the factors associated with both VCT uptake and HIV-1 infection, which could bias the prevalence estimates based on PMTCT data. RESULTS: In 2001-2003, the age-standardized prevalence was similar (11.1% in the anonymous surveillance group and 10.9% in the VCT group). The estimates were also similar when compared for each year tested. Analogously, no important differences were observed in age-specific prevalence. Of the factors associated with HIV-1 infection, only time of residence at current address [prevalence proportion ratio (PPR) = 1.05; 95% confidence interval (CI), 1.00-1.10], marital status (PPR = 1.05; 95% CI, 1.01-1.10) and partner's occupation (PPR = 1.05; 95% CI, 1.01-1.10) were associated with VCT uptake, yet the associations were weak. CONCLUSIONS: The prevalence estimated based on the VCT data collected as part of the PMTCT programme could be used for HIV-1 surveillance in North Uganda. At the national level, however, it needs to be evaluated whether PMTCT data could replace, or instead be combined with, the data from sentinel surveillance.     

The effect of rapid HIV-1 testing on uptake of perinatal HIV-1 interventions: a randomized clinical trial

OBJECTIVE: We examined whether HIV-1 testing using a rapid assay increases the proportion of pregnant women obtaining HIV-1 results and the uptake of perinatal HIV-1 interventions. METHODS: Pregnant women attending public health clinics in Nairobi were offered voluntary counselling and testing for HIV-1. Consenting women were randomly assigned to receive either rapid or conventional HIV-1 testing. Women randomly assigned to rapid testing were allowed to receive same-day results or to return later. The results for women randomly assigned to conventional enzyme-linked immunosorbent assay (ELISA) testing were available after 7 days. HIV-1-infected women were referred for antiretroviral prophylaxis to prevent mother-to-child transmission of HIV-1. RESULTS: Among 1282 women offered voluntary HIV-1 testing and counselling, 1249 accepted testing, of whom 627 were randomly assigned to rapid testing and 622 to conventional testing. The median duration between testing and obtaining results was 0 days for women who received rapid testing compared with 11 days for women who received conventional testing. The percentage receiving HIV-1 results was significantly higher among women who received rapid testing compared with conventional testing. Of 161 HIV-1-seropositive women, only 24 received antiretroviral prophylaxis. The uptake of perinatal HIV-1 interventions did not differ between HIV-1-seropositive women randomly assigned to rapid testing or conventional ELISA testing. CONCLUSION: Rapid HIV-1 testing significantly increased the proportion of women receiving HIV-1 results, which is important for sexual and perinatal HIV-1 prevention. The challenge remains to improve the uptake of perinatal HIV-1 interventions among HIV-1-seropositive women.     

Uptake of HIV voluntary counselling and testing services in rural Tanzania: implications for effective HIV prevention and equitable access to treatment

Objective To describe the associations between socio‐demographic, behavioural and clinical characteristics and the use of HIV voluntary counselling and testing (VCT) services among residents in a rural ward in Tanzania. Methods Eight thousand nine hundred and seventy participants from a community‐based cohort were interviewed, provided blood for research HIV testing, and were offered VCT. Univariate and multivariate logistic regression was used to identify socio‐demographic, clinical and behavioural factors associated with VCT use. Results Although 31% (1246/3980) of men and 24% (1195/4990) of women expressed an interest in the service, only 12% of men and 7% of women subsequently completed VCT. Socio‐demographic factors, such as marital status, area of residence, religion and ethnicity influenced VCT completion among males and females in different ways, while self‐perceived risk of HIV, prior knowledge of VCT, and sex with a high‐risk partner emerged as important predictors of VCT completion among both sexes. Among males only, those infected with HIV for 5 years or less tended to self‐select for VCT compared to HIV‐negatives (adjusted odds ratio = 1.43; 95% CI: 0.99–2.14). This contributed to a higher proportion of HIV‐positive males knowing their status compared to HIV‐positive females. Conclusions In this setting, a disproportionate number of HIV‐positive women are failing to learn their status, which has implications for equitable access to onward referral for care and treatment services. Evidence that some high‐risk behaviours may prompt VCT use is encouraging, although further interventions are required to improve knowledge about HIV risk and the benefits of VCT. Targeted interventions are also needed to promote VCT uptake among married women and rural residents.     

HIV incidence during a cluster-randomized trial of two strategies providing voluntary counselling and testing at the workplace, Zimbabwe

OBJECTIVE: To investigate HIV incidence during a trial of two voluntary counselling and testing (VCT) strategies. Counselling may promote beneficial behavioural change, although knowledge of negative status does not appear to contribute further benefit. DESIGN: The parent cluster-randomized trial demonstrated much greater uptake of VCT when counselling and rapid testing were available on-site (intensive VCT) than through pre-paid vouchers to an external provider (standard VCT). Anonymous HIV tests had been requested from all employees at enrolment and after 2 years intervention. METHODS: The study setting was 22 businesses in Harare, Zimbabwe. Participants were 3146 HIV-negative individuals remaining in employment at the end of intervention, of whom 2966 (94.3%) consented to repeat testing. VCT linked to basic HIV care was provided and the main outcome measures were HIV incidence under each study arm, as a retrospective secondary analysis. RESULTS: Mean VCT uptake in this cohort was 70.7 and 5.2%, respectively, in the intensive and standard arms. Crude HIV incidence was 1.21 per 100 person-years, with non-significantly higher rates in the intensive VCT arm [mean site incidence 1.37 and 0.95 per 100 person-years, respectively; adjusted rate ratio 1.49 (95% confidence interval 0.79-2.80). CONCLUSIONS: Highly acceptable VCT did not reduce HIV incidence in this predominantly male cohort. HIV incidence was highest in the high uptake VCT arm, lending support to a US trial in which rapid testing appeared to have adverse behavioural consequences in some HIV-negative clients. Careful comparison of outcomes under different counselling and testing strategies is needed to maximize HIV prevention from global scale-up of VCT.     

Recent HIV type 1 infection among participants in a same-day mobile testing pilot study in Zimbabwe

We estimated HIV-1 incidence and characterized risk factors associated with recent infection among participants of a mobile HIV voluntary counseling and testing (VCT) pilot program in two communities in Zimbabwe (N = 1096). HIV-1 infection was diagnosed using a parallel rapid testing algorithm. Recent HIV-1 infections were characterized using the BED immunoglobulin G capture enzyme immunoassay (BED-CEIA). HIV prevalence was 28.9% overall and nearly twice as high in women compared to men (39.5% vs. 21.4%, p < 0.001). HIV-1 incidence was 1.91% and was comparable between men and women (1.99% vs.1.88%; p = 0.626). Although not significant, the proportion of recent infections among all infections was highest among persons ages 25 to 34 years old (10.5%) for both men (11.9%) and women (9.2%). Persons recently infected compared to those with long-term infections were more likely to report STD symptoms (33% vs. 13%; OR = 3.2; p = 0.075) and prior STD treatment (13% vs. 6%; OR = 3.4; p = 0.187) in the previous 6 months. There were no associations found between recent versus long-term HIV infection status and perceived risk or expectation of negative test results. Recent HIV-1 infection detection among mobile VCT participants is a valuable measure for tracking the spread of the epidemic among persons who might otherwise not have access to HIV testing due to practical and logistical barriers. Mobile VCT presents opportunities to expand HIV testing services and evaluate at-risk populations within community settings. Given the challenges of longitudinal cohort studies, recent infection may be a practical endpoint for community-based prevention intervention trials employing mobile testing.     

Low male partner participation in antenatal HIV counselling and testing in northern Tanzania: implications for preventive programs

This study aimed to describe the prevalence and predictors for male partner participation in HIV voluntary counselling and testing (VCT) at two primary healthcare clinics in Moshi urban, Tanzania as well as the effect of partner participation on uptake of HIV perinatal interventions. Pregnant women (n = 2654) in their third trimester, participating in a prevention of mother to child tranmission (PMTCT) program between June 2002 and March 2004 were encouraged to inform and invite their partners for HIV-VCT. Trained nurses conducted pre-test counselling, interviews, clinical examinations and blood sampling from the participating women and their partners. Test results were presented and post-test counselling was conducted individually or in couples, depending on the wishes of the participants. Three-hundred-and-thirty-two male partners (12.5%) came for HIV-VCT. A high proportion (131; 40%) came after the woman had delivered. HIV-seropositive women whose partners attended were three times more likely to use Nevirapine prophylaxis, four times more likely to avoid breastfeeding and six times more likely to adhere to the infant feeding method selected than those whose partners didn't attend. Women were more likely to bring their partner for VCT if they collected their own test results, were living with their partner, had a high monthly income and had expressed at enrolment the intention to share HIV results with their partner. Although PMTCT programs are presumably a good entry point for male involvement in prevention of sexual and perinatal HIV transmission, this traditional clinic-based approach reaches few men. Given the positive influence male participation has on the acceptance of perinatal interventions, a different approach for promoting male participation in VCT is urgently required. Within PMTCT programs, counseling should emphasize the advantages of partner participation to encourage women to inform and convince male partners to come for VCT. Also, promotion of couple VCT outside antenatal settings in male friendly and accessible settings should be given priority.     

Post-abortion care and voluntary HIV counselling and testing--an example of integrating HIV prevention into reproductive health services

OBJECTIVE: To assess the acceptance and outcome of voluntary HIV counselling and testing (VCT) among women who had an unsafe abortion. METHOD: 706 women were provided with post-abortion contraceptive service and offered VCT. We collected data on socioeconomic characteristics and contraceptive use and determined the HIV status of those who accepted VCT. Using a nested case-control design, we compared women who accepted HIV testing with women who did not. To study the association between socioeconomic factors, HIV testing acceptance and condom use in more detail, we did stratified analyses based on age and marital status. RESULTS: 58% of the women who had an unsafe abortion accepted HIV testing. Women who earned an income were more likely to accept testing than housewives. Women who accepted testing were more likely to accept using a condom. The HIV prevalence rate was 19% among single women aged 20-24 years and 25% among single women aged 25-45 years. CONCLUSION: HIV testing and condoms were accepted by most women who had an unsafe abortion. The poor reproductive health of these women could be improved by good post-abortion care that includes contraceptive counselling, VCT and condom promotion.     

Trends in the uptake of voluntary counselling and testing for HIV in rural Tanzania in the context of the scale up of antiretroviral therapy

Objectives To describe trends in voluntary counselling and testing (VCT) use and to assess whether high‐risk and infected individuals are receiving counselling and learning their HIV status in rural Tanzania. Methods During two rounds of linked serological surveys (2003–2004 and 2006–2007) with anonymous HIV testing among adults, VCT was offered to all participants. The crude and adjusted odds ratios for completing VCT in each survey were calculated to compare uptake by demographic, behavioural and clinical characteristics, stratified by sex. Repeat testing patterns were also investigated. Results The proportion of participants completing VCT increased from 10% in 2003–2004 to 17% in 2006–2007, and among HIV‐infected persons from 14% to 25%. A higher proportion of men than women completed VCT in both rounds, but the difference declined over time. Socio‐demographic and behavioural factors associated with VCT completion were similar across rounds, including higher adjusted odds of VCT with increasing numbers of sexual partners in the past 12 months. The proportion having ever‐completed VCT reached 26% among 2006–2007 attendees, with repeat testing rates highest among those aged 35–44 years. Among 3923 participants attending both rounds, VCT completion in 2006–2007 was 17% among 3702 who were HIV negative in both rounds, 19% among 124 who were HIV infected in both rounds and 22% among 96 who seroconverted between rounds. Conclusion VCT services are attracting HIV‐infected and high‐risk individuals. However, 2 years after the introduction of antiretroviral therapy, the overall uptake remains low. Intensive mobilisation efforts are needed to achieve regular and universal VCT use.     

Voluntary counselling,HIV testing and adjunctive cotrimoxazole reduces mortality in tuberculosis patients in Thyolo,Malawi

OBJECTIVES: To assess the feasibility and effectiveness of voluntary counselling, HIV testing and adjunctive cotrimoxazole in reducing mortality in a cohort of tuberculosis (TB) patients registered under routine programme conditions in a rural district of Malawi. DESIGN: 'Before' and 'after' cohort study using historical controls. METHODS: Between 1 July 1999 and 30 June 2000 all TB patients were started on standardized anti-TB treatment, and offered voluntary counselling and HIV testing (VCT). Those found to be HIV-positive were offered cotrimoxazole at a dose of 480 mg twice daily, provided there were no contraindications. Side-effects were monitored clinically. End-of-treatment outcomes in this cohort (intervention group) were compared with a cohort registered between 1 July 1998 and 30 June 1999 in whom VCT and cotrimoxazole was not offered (control group). FINDINGS: A total of 1986 patients was registered in the study: 1061 in the intervention group and 925 in the control cohort. In the intervention group, 1019 (96%) patients were counselled pre-test, 964 (91%) underwent HIV testing and 938 (88%) were counselled post-test. The overall HIV-seroprevalence rate was 77%. A total of 693 patients were given cotrimoxazole of whom 14 (2%) manifested minor dermatological reactions. The adjusted relative risk of death in the intervention group compared with the control group was 0.81 (P < 0.001). The number needed to treat with VCT and adjunctive cotrimoxazole to prevent one death during anti-TB treatment was 12.5. INTERPRETATION: This study shows that VCT and adjunctive cotrimoxazole is feasible, safe and reduces mortality rates in TB patients under routine programme conditions.     

Evaluation of 2 techniques of HIV pre-test counselling for pregnant women in west Africa. DITRAME Study Group.

This study compares the effect of group and individual pre-test counselling on uptake of HIV voluntary counselling and testing (VCT) by African pregnant women and knowledge about HIV/AIDS in 2 antenatal clinics of Bobo-Dioulasso, Burkina Faso. Pre-test counselling was offered to 3958 pregnant women, 927 by group counselling and 3031 by individual counselling. Acceptance of the test improved with individual counselling, which was already high with group counselling (93.3% versus 89.4%). The return rate for results was independent of the pre-test counselling technique. At post-test session, knowledge about HIV/AIDS was better after group than individual counselling, except for reporting the existence of an asymptomatic stage of HIV infection. At a public health level, group pre-test counselling can be easily integrated into existing sessions of antenatal care counselling, routinely performed by the current clinic staff. Our findings may help programme managers in the field of maternal and child health to choose optimal options of pre-test counselling adapted to local circumstances in resource-poor settings.     

Condom use after voluntary counselling and testing in central Mozambique

OBJECTIVE: To evaluate the efficacy of voluntary counselling and testing (VCT) for HIV/AIDS in changing risky sexual behaviour in central Mozambique. METHOD: Longitudinal cohort study of men and women aged at least 18 years from October 2002 to June 2003. We interviewed 622 participants in VCT groups and 598 in non-VCT groups. The interviews occurred before counselling and 4 and 6 months afterwards. RESULTS: Reported use of condoms while having sex with a friends/prostitute increased over each time period in the VCT group and between baseline and first visit in the non-VCT group. Both men and women in the VCT group increased their condom use over time, but the women in the non-VCT group did not. Reported always/sometimes use of condoms for both literate and illiterate subjects was higher and rose over time in the VCT group. CONCLUSION: People who undergo voluntary counselling and testing fro HIV/AIDS change their behaviour, presumably as a result of their counselling.     

Positive and negative life events after counselling and testing: the Voluntary HIV-1 Counselling and Testing Efficacy Study

INTRODUCTION: The results of the Voluntary HIV-1 Counselling and Testing Efficacy Study support the efficacy and cost-effectiveness of HIV voluntary counselling and testing (VCT) for reducing risk behaviors in three developing countries. METHODS: This report explores the social consequences of HIV VCT by examining the incidence of positive and negative life events at the first follow-up (an average of 7.3 months after recruitment). The incidence of positive and negative life events was compared between: (i) those who were randomly assigned to HIV VCT versus health information (HI); (ii) those who tested seronegative and those who tested seropositive; and (iii) those who disclosed their serostatus and those who did not. RESULTS: The occurrence of most negative life events was rare (0--4%); positive life events were more common (17--39%). With few exceptions, those assigned to HIV VCT were no more likely to experience negative life events than those who were assigned to HI. For individuals, positive serostatus was associated with increased support from health professionals, the break-up of a marriage and being neglected or disowned by their family. Serodiscordant couples with an HIV-positive woman were most likely to report the break-up of a marriage (20 versus 0--7% for other groups) and the break-up of a sexual relationship (45 versus 22--38% for other groups). Disclosure was associated with strengthening of a sexual relationship except for HIV-seropositive women. CONCLUSION: These findings, in combination with findings supporting the efficacy and cost-effectiveness of HIV VCT, support the dissemination of HIV VCT with appropriate support services in developing countries.     

HIV incidence and risk behaviours after voluntary HIV counselling and testing (VCT) among adults aged 19-35 years living in peri-urban communities around Chiang Mai city in northern Thailand, 1999

The Thai government began HIV voluntary counselling and testing (VCT) in all provinces in 1992. We evaluated HIV incidence after participants utilized VCT and its effect on risk behaviours among northern Thai adults aged 19-35 years. A total of 924 men and 1,327 women volunteered to participate in the study. Subjects were counseled, interviewed (socio-demographic, HIV risk behaviour, and HIV testing history), and tested for HIV infection at baseline and at 6 months follow-up. All participants were provided group pre-test counselling; HIV test results were provided in individual confidential post-test counselling. Overall, 329 of 391 men and 621 of 669 women who reported a prior HIV test before participating in our study reported negative results at the previous test. Of these, nine men and 13 women tested positive at baseline, giving incidence rates of 1.04 and 0.69 per 100 person years (PY), respectively. Recent risk behaviour was rare; as a result, the effects of VCT on risk behaviours among the study participants could not be determined. The HIV incidence after VCT among this study population is substantial. Studies to investigate factors associated with HIV incidence among VCT clients could provide insights for more effective HIV prevention.     

HIV voluntary counselling and testing in Nakuru, Kenya: findings from a community survey

OBJECTIVES: HIV voluntary counselling and testing (VCT) is important for prevention, detection and treatment of HIV infection. A study was conducted to determine the extent of utilization of VCT, and to study the attitudes and preferences of the community regarding VCT. METHODS: A total of 301 adults, aged 18-49 years, residing in Nakuru, Kenya were randomly selected using a two-stage sampling process. A self-administered questionnaire delivered during home visits was used to collect data over a 4-week period. RESULTS: The majority of study participants (184 of 287; 64.1%) had never been tested for HIV; 77 (26.8%) had received VCT, and 26 (9.1%) had received HIV testing without counselling. A total of 219 (78.2%) of the 280 responding participants expressed readiness to have VCT. The majority of participants (216 of 296; 73%) preferred VCT, while 46 (15.5%) preferred testing without counselling. The majority (227; 76.7%) preferred couple testing and dedicated clinics and private doctors' offices as testing facilities. The choice of a nearby facility was ranked above the provision of anonymity by most participants (162 of 298; 54.4%; vice versa for 136 of 298; 45.6%). CONCLUSIONS: With HIV/AIDS continuing to be a major public health concern in Kenya, the issues surrounding acceptance and use of VCT need to be addressed. Enhancing community awareness of the benefits of early HIV diagnosis, providing couple-based VCT as an integral part of VCT and increasing access to VCT testing sites may enhance utilization of VCT.     

Responses to VCT for HIV among young people in Kampala,Uganda

Attitudes to voluntary counselling and testing (VCT) for HIV among young men and women in a slum area of Kampala, Uganda, were studied through 22 individual semi-structured interviews and 5 focus group discussions. Attitudes to VCT ranged from having no problem with the procedure to being very reluctant. Despite fear of stigma, the participants perceived 'positive living' after HIV testing as realistic. VCT was regarded as an important step to avoid HIV infection, but informants expressed the need for the service to be more accessible in terms of cost, time and quality of pre- and post-test counselling. We argue that counselling without HIV testing should be available for those who are reluctant to test. Poverty and gender power imbalances appeared to limit youths' possibility of making rational decisions about sexual behaviour and accessing VCT. The importance of considering the context in which such issues are being negotiated and decided is highlighted.