title: Uptake contexts and perceived impacts of HIV testing and counselling among adults in East and Southern Africa: A meta-ethnographic review.
abstract: BACKGROUND
  HIV testing and counselling (HTC) interventions are key to controlling the HIV epidemic in East and Southern Africa where HTC is primarily delivered through voluntary counselling and testing (VCT), provider initiated testing and counselling (PITC), and home-based counselling and testing (HBVCT). Decision making processes around uptake of HTC models must be taken into account when designing new interventions. Counselling in HTC aims to reduce post-test risk taking behaviour and to link individuals to care but its efficacy is unclear. This meta-ethnography aims to understand the contexts of HTC uptake in East and Southern Africa and to analyse the perceived impacts of counselling-based interventions in relation to sexual behaviour and linkage to care.
  
  
  METHODS
  We conducted a systematic literature review of studies investigating HTC in East and Southern Africa from 2003 -April 2014. The search and additional snowballing identified 20 studies that fit our selection criteria. These studies were synthesised through a thematic framework analysis.
  
  
  RESULTS
  Twenty qualitative and mixed-methods studies examining impacts of HTC models in East and Southern Africa were meta-synthesised. VCT decisions were made individually while HBVCT decisions were located in family and community units. PITC was associated with coercion from healthcare providers. Low quality counselling components and multiple-intersecting barriers faced by individuals mean that counselling in HTC was not perceived to be effective in reducing post-test risk behaviour and had limited perceived effect in facilitating linkage to care.
  
  
  CONCLUSIONS
  HBVCT is associated with minimal stigma and should be considered as an area of priority. Counselling components in HTC interventions were effective in transmitting information about HIV and sexual risk, but were perceived as ineffective in addressing the broader personal circumstances preventing sexual behaviour change and modulating access to care.
authors.affiliation: Sigma Research, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine. London, United Kingdom.
authors.forename: T Charles
authors.initials: TC
authors.lastname: Witzel
authors.affiliation: Malawi-Liverpool Wellcome Trust Clinical Research Programme. Liverpool School of Tropical Medicine. Blantyre, Malawi.
authors.forename: Wezzie
authors.initials: W
authors.lastname: Lora
authors.affiliation: Department of Public Health and Policy, London School of Hygiene and Tropical Medicine. London, United Kingdom.
authors.forename: Shelley
authors.initials: S
authors.lastname: Lees
authors.affiliation: Malawi-Liverpool Wellcome Trust Clinical Research Programme. Liverpool School of Tropical Medicine. Blantyre, Malawi.|Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Nicola
authors.initials: N
authors.lastname: Desmond
mesh_terms: D000328:Adult; D003376:Counseling; D015658:HIV Infections / Q000175:diagnosis* / Q000208:ethnology / Q000523:psychology*; D015497:HIV-1; D006801:Humans; D008403:Mass Screening / Q000523:psychology*