HIV counselling and testing: overemphasizing high acceptance rates a threat to confidentiality and the right not to know

Objective: To examine factors affecting the readiness for HIV-related volun tary confidential counselling and testing (VCT). Methods: In a population-based HIV survey in selected urban and rural areas in Zambia, adults aged greater than or equal to 15 years were selected by stratified random cluster sampling. The participants were asked to provide a saliva sample for anonymous HIV testing (n = 4812, consent rate 93.5%) an d, as a part of an interview, were asked about previous HIV testing experie nce and if they wished to be counselled and tested for HIV. Those indicatin g interest (initially willing) were provided with an invitation letter to s ee a counsellor. In rural areas, VCT was provided by personnel brought in f rom outside the local community, whereas in urban areas it was provided by locally recruited staff. Results: The overall HIV test rate was 6.5%, but rates appeared to be consi derably biased towards higher educational groups, The proportion initially willing was 37% while 3.6% actually came for counselling and were tested (9 .3% of those initially willing), of which 47% returned for the result. Actu al use was four to five times higher in rural compared with urban areas. Se lf-perceived risk and high-risk behaviour were positively associated with i nitial willingness but not with actual use. Conclusions: The readiness for VCT in the general population was found to b e very low. Provision factors such as concerns about confidentiality and le ngth of time waiting for the test result contributed to the low utilization rate. Results of this study contrast sharply with reported VCT acceptance rates of 70-90% among women attending antenatal care in Zambian and in othe r African populations, suggesting an urgent need to evaluate testing policy and practice of antenatal VCT in particular. (C) 1999 Lippincott Williams & Wilkins.