Effect of voluntary counselling and testing and a negative HIV result on risk behaviour: a qualitative longitudinal study in a Zambian mining community

Background: Countries in sub-Saharan Africa are scaling up access to Voluntary Counselling and Testing (VCT) services as a strategy for HIV prevention, treatment, care and support. The international and national push to achieve targets for anti-retroviral therapy scale up has emphasised VCT as an entry point to treatment, with follow-up mostly directed at those who test positive. Yet over 60% of those testing are HIV negative. Limited understanding of how HIV voluntary counselling and testing, and receipt of a negative result impact on sexual behaviour has resulted in underdeveloped support for those testing HIV negative. Aims: To gain the perspective of those who have tested HIV-negative on the following: (1) the decision making process that precedes attendance for voluntary counselling and testing; (2) how voluntary counselling and a negative test result influence sexual behavioural intentions and reported subsequent behaviour; and (3) support systems and networks that would enhance the respondent’s ability to remain HIV negative. Method: Qualitative longitudinal study utilising semi-structured interviews, six months apart, with people who have tested negative and three one-off focus group discussions with counsellors. Participants were purposively sampled from VCT centres in two mining towns in Zambia. Interviews were digitally recorded, transcribed verbatim and analysed thematically with the aid of the qualitative data analysis software, Nvivo7. Cross-sectional analysis of all data sets was conducted and paired transcripts were analysed longitudinally to assess change over time. Results: Forty-two HIV-negative people were interviewed, with thirty-one returning for the follow-up interview (74% return rate). VCT was perceived as ‚testing for HIV‛. Before attending VCT most participants had gone through a protracted period of angst, resulting in a resolution to reduce number of partners, use condoms or abstain from sex. Counselling affirmed life choices, rather than initiating them. Although perception of the risk of HIV increased, misconceptions about HIV transmission persisted post-counselling. The negative test result provided impetus and resolve to implement or maintain life change. Themes identified were: (1) recognising personal susceptibility to HIV infection; (2) emotional and cognitive engagement with the problem of testing; (3) a driving need to know status (regardless of test result); and (4) empowerment and being in control providing the ability to plan for the future. Analysis of post-test support needs revealed two further themes: (1) reinforcement of behaviour change through additional knowledge, supportive networks, and life-skills training; and (2) access to recreational activities. There was no reported post-test increase in unsafe sexual behaviour among those that returned for the follow-up interview. Focus group findings reinforced those from interviews. Conclusions: This study has shown that in this population of people who tested HIV-negative: 1. the majority made life changes before attending VCT and used VCT to know their status 2. counselling consolidated pre-test decisions about risk behaviour and testing provided motivation to adopt safer behaviour and to maintain previous low- or no-risk behaviour and 3. there is a felt need for post-testing recreational activities, further HIV/AIDS education and participation in HIV prevention activities. Recommendations include: (1) the promotion of community-based interactive one-to-one and group information, education and communication (IEC) (to aid understanding and progression to the point where testing appears to be of optimum benefit) ; (2) referral to post-test support options such as support groups and inclusion on a text messaging list should be made available; and (3) post-test intervention strategies, for example, provision of result-specific IEC materials and active involvement in prevention activities should be developed and evaluate