Acceptability and Barriers of the Home-Based Voluntary Counseling and Testing Model in the First Six Months of Service in Three Rural Sites in Amhara, Ethiopia

Abstract

<bold> Specific Aims: </bold> The objective of this research was to evaluate a home-based HIV counseling and testing (HBVCT) pilot implemented in three Ethiopian sites during the first six month of implementation (January 1, 2011 to June 30, 2011). This study sought to document the experiences and challenges from the community voluntary counseling and testing (VCT) counselors providing the HBVCT service as well as specific challenges and barriers faced by ever-married community members. <bold>Setting:</bold> The pilot HBVCT program was implemented in eight sites in four regions of Ethiopia. The three sites in the Amhara Region were selected for this study. These sites (and rural kebeles) are Bahir Dar (Tis Abay, Andasa), Dessie (Addis Mender, Habru 01), and Gondar (Loza Mariam, Tekele Hymenot). These sites were selected because they are in the Amhara National Regional State. <bold>Methods:</bold> Secondary counseling and testing reports were collected from each site to analyze the clients' demographic information and testing results. In-depth interviews were conducted with the community VCT counselors and the senior VCT counselors in all three sites. Male and female focus group discussions were held in each community for ever-married men and women age 18 to 59 years old. Counselors were asked about the challenges of providing home-based services and their experience during the first six months of implementation. The focus group participants were asked about the community's perception of the HBVCT program, benefits, and barriers to acceptance. <bold>Results:</bold> 6,757 clients were tested in the Amhara Region during the first six months of implementation. In all sites, 59.26 percent of clients were female, the age of clients ranged from less than one year to over 99 years of age, 45.37 percent were illiterate, and 79.38 percent reported never before being tested. The qualitative interview and focus group data revealed three major themes: acceptance, challenges and barriers to testing, and benefits of HBVCT. Acceptance included both the general acceptance of the service and the acceptance of the locally selected VCT counselors. Challenges faced by clients were primarily related to understanding and fear of stigma or discrimination. Challenges faced by the counselors were mostly regarding the logistical challenges of providing home-to-home service and the technical challenges of providing counseling service. Benefits of the home-based service included reduction of traditional barriers to counseling and testing and normalization of VCT, making it easier and more socially acceptable to receive testing. <bold>Conclusions: HBVCT may provide an important avenue for testing Ethiopia's rural population. In this pilot, 79.38 percent of the Amhara clients had never before been tested for HIV, higher than other reported findings highlighting the need for an alternate testing model (1). Through this study, the HBVCT model was found to be accepted by community members in the three Amhara sites. In addition, community members were comfortable and reported a sense of increased confidentiality when receiving VCT services in their homes, even with a local community VCT counselor. Acceptability and normalization of counseling and testing were strengthened by community-based HIV and VCT education or promotion activities. This occurred by reducing some challenges faced by the HBVCT counselors as well as increasing acceptability among the community. The logistics and discussion of HIV counseling and testing remains a barrier for couples. However, HBVCT can act as a catalyst for couples to discuss and receive testing, especially for couples with low levels of education and for those who reside in rural communities. As the only qualitative and quantitative evaluation of a HBVCT program in Ethiopia, further research is needed to better understand the cost and prevention benefits of home-based service.