| How do
we know that VCT is an effective prevention intervention?
A case in question for CEA
There is a Turkish proverb that reads: The tortoise
in its shell says, 'What a big place I live in'
. Indeed, the world can seem rather predictable
to a big fish in a small pond. This concept underlies
the emphasis on replicable cross-contextual research
in the CEA field. Few studies have been conducted
to test the efficacy of VCT interventions. An
example is work done by the Voluntary HIV-1 Counseling
and Testing Efficacy Study Group , to determine
the efficacy of HIV-1 VCT in reducing unprotected
intercourse. This efficacy study is the only randomized
controlled study on the impact of VCT in developing
countries and is also the only randomized controlled
study in the world to look at the impact of VCT
on couples.
The research findings relate VCT to decreased
unprotected sex with non-primary and primary partners
in HIV positive individuals and couples respectively
(i.e. decline in risk behaviour in the infected
group). The investigators conclude that the findings
lend support for the use of VCT in HIV-1 prevention
in developing countries, especially in sub-Saharan
Africa and note further: HIV counseling is thus
an important tool in reducing HIV-risk behavior
for high-risk populations. A CEA of the program
showed that “cost-effectiveness increased
in tandem with the proportion of HIV-positives
in the client population”.
The question to ask from a future cost-effectiveness
perspective is: What standards can be applied
in the South African context to determine the
effectiveness of VCT interventions? In this regard,
do Coates et al’s findings, for example,
provide sufficient evidence of the cross-contextual
effectiveness of VCT as a prevention intervention?
Similarly, how can we improve on previous research?
For example, what do we make of the observation
in the latter study that no significant differences
in unprotected sex with non-enrollment partners
were found among couples. Also: What comments
do we have concerning the use of self-reports
in a quasi-experimental field research setting?
And: What directions for future research can be
drawn from the lack of record on results of STI
treatment observations in the study? One could
also ask: What direction does the research provide
to researchers, intervention designers and implementers
concerning HIV negative clients, for example?
Research that makes recommendations on the basis
of existing models for the piloting of new models
is important. As such the most important question
may be: Under what circumstances do VCT interventions
maximize risk-reduction?
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