Strategies that attempt to modify behaviour remain the cornerstone of HIV prevention efforts . Couples' VCT can provide life-saving benefits, reduce HIV transmission, sexually transmitted infections, and unintended pregnancies among couples [7, 9, 30–40]. There is now a growing consensus that CVCT should be widely disseminated, but many cultural and logistical obstacles remain . This study confirms that influential members of the community are willing and able to promote CVCT in Africa. Although there were differences in the impact of CVCT promotion between Kigali, Rwanda and Lusaka, Zambia, the predictors of success were similar.
We recruited and trained a broad range of Influence Network Agents to promote CVCT through one-on-one contacts and written invitations. Our previous work successfully used paid Community Workers (CWs) as full-time promoters of CVCT. When CW outreach was discontinued due to achievement of research enrollment targets, attendance at CVCT sites declined [4, 5]. The INA model was implemented in order to increase community awareness of CVCT and ensure sustainability.
INAs self-identified with one of four main categories in this study, but many INAs wore more than one 'hat' and used a variety of networks, including friends, family, professional contacts, and social settings to promote CVCT. Zambian INAs were more likely than their Rwandan counterparts to identify their faith-based 'hat' as their most prominent role in CVCT promotion. This may be due to the central role that religion plays in Zambian culture .
INAs were most effective when addressing couples, a strategy that removes the pressure on one spouse to carry the message to the other. Delivering invitations in settings that allowed discreet conversation was important because it allowed fear and stigma to be openly discussed. Fewer than one in ten invitations were delivered in INA homes, but of those one third to one half resulted in couples seeking testing. This may also be indicative of the strength of the relationship between the INA and the couple. Locations such as the couples' home and workplace also proved to be more conducive to successful invitation than public locations such as markets, churches, or social gatherings as noted by others involved in VCT/CVCT research in Zambia, Uganda, and Malawi [15–18]
The response rate among couples invited for CVCT by INAs in Kigali was substantially higher than that in Lusaka. Rwandan INAs were more likely to invite people personally known to them, to invite both members of the couple, and to deliver invitations in their own homes than their Zambian colleagues. Invitations in Rwanda were also more likely to be preceded by a public endorsement of CVCT. Other potential explanations for this difference include possible increased receptivity among Rwandan couples, more selective distribution of invitations on the part of Rwandan INAs based on likelihood of attendance, and/or a combination of greater persuasiveness on the part of Rwandan INAs. Factors unrelated to the study no doubt also played a role. Rwandans have one local language, Kinyarwanda. In comparison, 72 dialects from five major language groups in Zambia are spoken in Lusaka. Kigali is also smaller than Lusaka and transport is easier to organize, which reduced the logistical obstacles to CVCT.
Fear of stigma among married couples is common [6, 42, 43] and was reported by many INAs in the weekly follow-up meetings as an obstacle to their work. Public endorsement of CVCT was used by some INAs to overcome this fear, an effective strategy that addresses psychosocial barriers to accessing clinic services . However, many INAs were reluctant to make public announcements because they had no experience with public speaking and feared being stigmatized themselves. It should also be noted that since more than half of those people being invited to CVCT were known by the INAs, the identification and training of more INAs over time would be necessary in order to have a continued impact throughout the community.
Although the results of this study are encouraging, the fact that three-quarters of invited couples in Kigali and nine in ten couples in Lusaka did not seek CVCT confirms that obstacles remain. Lack of time and the money needed for transportation have been cited as obstacles to VCT [12, 20] and CVCT . It may be that had the INAs been able to provide home based testing or been accompanied by someone trained to do so, the uptake of CVCT would have been higher. Strategies such as mobile units and decentralization of CVCT should be developed to bring services closer to the clients.