title: The impact of voluntary counselling and testing services on sexual behaviour change and HIV incidence: observations from a cohort study in rural Tanzania.
abstract: BACKGROUND
  It is widely assumed that voluntary counselling and testing (VCT) services contribute to HIV prevention by motivating clients to reduce sexual risk-taking. However, findings from sub-Saharan Africa have been mixed, particularly among HIV-negative persons. We explored associations between VCT use and changes in sexual risk behaviours and HIV incidence using data from a community HIV cohort study in northwest Tanzania.
  
  
  METHODS
  Data on VCT use, sexual behaviour and HIV status were available from three HIV serological surveillance rounds undertaken in 2003-4 (Sero4), 2006-7 (Sero5) and 2010 (Sero6). We used multinomial logistic regression to assess changes in sexual risk behaviours between rounds, and Poisson regression to estimate HIV incidence.
  
  
  RESULTS
  The analyses included 3,613 participants attending Sero4 and Sero5 (3,474 HIV-negative and 139 HIV-positive at earlier round) and 2,998 attending Sero5 and Sero6 (2,858 HIV-negative and 140 HIV-positive at earlier round). Among HIV-negative individuals VCT use was associated with reductions in the number of sexual partners in the last year (aRR Seros 4-5: 1.42, 95% CI 1.07-1.88; aRR Seros 5-6: 1.68, 95% CI 1.25-2.26) and in the likelihood of having a non-cohabiting partner in the last year (aRR Seros 4-5: 1.57, 95% CI 1.10-2.25; aRR Seros 5-6: 1.48, 95% CI 1.07-2.04) or a high-risk partner in the last year (aRR Seros 5-6 1.57, 95% CI 1.06-2.31). However, VCT was also associated with stopping using condoms with non-cohabiting partners between Seros 4-5 (aRR 4.88, 95% CI 1.39-17.16). There were no statistically significant associations between VCT use and changes in HIV incidence, nor changes in sexual behaviour among HIV-positive individuals, possibly due to small sample sizes.
  
  
  CONCLUSIONS
  We found moderate associations between VCT use and reductions in some sexual risk behaviours among HIV-negative participants, but no impacts among HIV-positive individuals in the context of low overall VCT uptake. Furthermore, there were no significant changes in HIV incidence associated with VCT use, although declining background incidence and small sample sizes may have prevented us from detecting this. The impact of VCT services will ultimately depend upon rates of uptake, with further research required to better understand processes of behaviour change following VCT use.
authors.affiliation: Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. caoimhe.cawley@lshtm.ac.uk.
authors.forename: Caoimhe
authors.initials: C
authors.lastname: Cawley
authors.forename: Alison
authors.initials: A
authors.lastname: Wringe
authors.forename: Emma
authors.initials: E
authors.lastname: Slaymaker
authors.forename: Jim
authors.initials: J
authors.lastname: Todd
authors.forename: Denna
authors.initials: D
authors.lastname: Michael
authors.forename: Yusufu
authors.initials: Y
authors.lastname: Kumugola
authors.forename: Mark
authors.initials: M
authors.lastname: Urassa
authors.forename: Basia
authors.initials: B
authors.lastname: Zaba
mesh_terms: D000293:Adolescent; D000328:Adult; D015331:Cohort Studies; D017280:Condoms; D003376:Counseling / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000453:epidemiology / Q000523:psychology*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012309:Risk-Taking; D012725:Sexual Behavior / Q000523:psychology* / Q000706:statistics & numerical data; D012747:Sexual Partners; D013636:Tanzania / Q000453:epidemiology; D055815:Young Adult