Confidential HIV testing and condom promotion in Africa. Impact on HIV and gonorrhea rates
S. Allen, A. Serufilira, J. Bogaerts, P. Van de Perre, F. Nsengumuremyi, C. Lindan, M. Carael, W. Wolf, T. Coates and S. Hulley
Department of Pathology, University of California, San Francisco 94105.
OBJECTIVE--We evaluated the impact of human immunodeficiency virus (HIV)
testing and counseling on self-reported condom and spermicide use and on
corresponding HIV seroconversion and gonorrhea rates in urban Rwandan
women. DESIGN--Prospective cohort study with 2 years of follow-up,
comparison of outcome variables before and after an intervention, and
condom use measured in a control group that did not receive the
intervention. SETTING--Outpatient research clinic in Kigali, the capital of
Rwanda. PARTICIPANTS--One thousand four hundred fifty-eight childbearing
women, 32% of whom were infected with HIV, were enrolled in a prospective
study in 1988, and followed at 3- to 6-month intervals for 2 years.
Follow-up was available for 95% of subjects at year 1 and 92% at year 2.
INTERVENTIONS--An acquired immunodeficiency syndrome (AIDS) educational
videotape, HIV testing and counseling, and free condoms and spermicide were
provided to all participants and interested sexual partners. MAIN OUTCOME
MEASURES--Self-report of compliance with condom-spermicide use and observed
incidence of HIV and gonorrhea. RESULTS--Only 7% of women reported ever
trying condoms before the intervention, but 22% reported condom use with
good compliance 1 year later. Women who were HIV-positive were more likely
to adopt condom use than HIV-negative women (36% vs 16%; P < .05).
Independent predictors of condom use, both in HIV-positive and in
HIV-negative women, included HIV testing and counseling of the male
partner, having a nonmonogamous relationship, and believing condoms were
not dangerous. Human immunodeficiency virus seroconversion rates decreased
significantly (from 4.1 to 1.8 per 100 person-years; P < .04) in women
whose partners were tested and counseled. The prevalence of gonorrhea
decreased substantially (13% to 6%; P < .05) among HIV-positive women,
with the greatest reduction among condom users (16% to 4%; P < .05).
CONCLUSION--A confidential HIV testing and counseling program was
associated with increased use of condoms and reduced rates of gonorrhea and
HIV in urban Rwandan women. The lack of risk reduction in HIV-negative
women whose partner's serostatus was unknown was of concern. Interventions
that promote HIV testing and counseling for both members of a couple should
be considered in other high-prevalence areas.
