Confidential HIV Testing and Condom Promotion in Africa

Abstract

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 the 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. (JAMA. 1992;268:3338-3343)