In Kigali, Rwanda's capital, the prevalence of HIV is 7.3% among those aged 15–49, the highest in the country . Prevention interventions have actively taken place in Rwanda since the late 1980s. Still, in 2002, Rwanda was one of the 10 African countries most affected by HIV/AIDS . At that time, prevention efforts based on serostatus awareness were not emphasized [1,3].
Without knowledge of HIV serostatus, the ability to counsel those with and at risk for HIV is limited . Routine testing and counseling for pregnant women began in 2001, and expanded to include individuals with symptoms of HIV with the advent of the Global Fund in 2003 and the United States President's emergency plan for AIDS relief (PEPFAR) in 2005 [5–7]. To date, approximately 21% of adults in sub-Saharan Africa know their HIV status . One particularly efficacious prevention program is couples’ HIV voluntary counseling and testing (CVCT) in which steady sexual partners are tested together, mutually disclose results, and receive counseling to develop risk-reduction plans based on their serostatus . Couples are a critical prevention point [9,10]; approximately, 70–90%  to 30%  of heterosexual HIV transmissions in sub-Saharan Africa occur within stable relationships. In Kigali, 6.2% of couples are in stable relationships in which partners do not share the same HIV status (discordant couples), one of the most vulnerable populations [1,3].
In 1988, Project San Francisco (PSF) evolved into a couples’ counseling and research center in Kigali after women attending antenatal clinics expressed an interest in having their husbands tested for HIV . PSF began CVCT promotions by providing pregnant women with invitations for their partners . Initially, demand for CVCT was low due to beliefs that monogamy is safe, fear, stigma, sex inequality, and lack of knowledge about CVCT services. A male-focused intervention was designed to overcome common misconceptions and was successful in increasing the number of husbands tested .
Community health workers have been successful in bridging the gap between individuals and healthcare systems . A prospective cohort study was conducted to test CVCT promotional models in two neighborhoods in Kigali. The Integrated Model of Community-Based Evaluation was used to guide development and implementation of the outreach program . Herein, we identify factors predicting uptake of CVCT in Kigali, Rwanda.
Three nonoverlapping Kigali neighborhoods were chosen as described elsewhere . Briefly, among nine neighborhoods considered as potential sites, three were selected based on comparable population size and infrastructure. We also sought to maximize distance between the neighborhoods to limit potential spillover effects. Two neighborhoods were then randomly selected to each receive active CVCT promotion combined with a stand-alone CVCT center; a mobile unit crossed over from one neighborhood to the other at the mid-point of the study. Each CVCT center and mobile unit could accommodate 30 couples/day. Intervention neighborhood catchment populations included 56 809 and 64 049 people, respectively, and duplicate invitation delivery was assumed to be rare. There were several kilometers between the three neighborhoods, none of which included the city center. The sequence of events and overview of the data collection and analysis plan are shown in Fig. 1.
Influence network leader and influence network agent recruitment and training
The results of a pilot study using only influence network agents (INAs)  indicated that public endorsements of CVCT by community leaders was associated with increased couples’ testing. The promotional intervention for this study was thus modified to include 26 influence network leaders (INLs) who then nominated 118 INAs and supported their promotional efforts by making public endorsements of CVCT. Public endorsements conducted by INLs included priests/pastors discussing CVCT during sermons, senior nurses giving talks to clinic patients, factory foremen encouraging employees to test with their spouses, or parent–teacher association (PTA) leaders presenting CVCT at PTA meetings.
Influence network leaders were recruited through referrals from national/citywide umbrella groups in the following networks: faith-based, health, private, and community-based/nongovernmental organization (CBO/NGO) groups. INLs received training from project physicians and senior counselors. INLs recommended INA candidates for interview, selection, and training. INAs who performed successfully in the pilot study  were recruited as trainers. Criteria for selection of INLs and INAs considered their scope of influence to avoid spillover effects between neighborhoods.
Training processes included instruction in invitation delivery methods and data collection, with a focus on approaching family, friends, neighbors, and social/work acquaintances as well as promoting door to door. INLs and INAs were encouraged to work together. For example, a church pastor INL might endorse CVCT during a sermon, and after the service, deacons (INAs) would distribute invitations to the congregation. Demographic questionnaires were completed by INLs and INAs at enrollment.
Between July 2004 and December 2005, INAs distributed invitations containing CVCT facility directions, description of services, and hours of operation. Invitations were delivered to couples or individuals who indicated they were in steady sexual relationships (Fig. 1). INAs submitted data forms bi-weekly and were paid $0.30/invitation issued and $3/couple tested. Couples attending CVCT services received transport reimbursement, lunch, and childcare at CVCT sites.
Couples’ voluntary counseling and testing
Couples’ voluntary counseling and testing procedures are detailed elsewhere [20,21]. Briefly, after giving written informed consent, couples receive pretest counseling and provide blood for screening and confirmatory rapid HIV tests . Couples receive confidential HIV test results during joint post-test counseling. Mobile testing was scheduled weekly based on availability of resources/facilities such as community centers, schools, churches, or any available building with a large room for group discussions and several small rooms for counseling. This research was conducted with Emory University Institutional Review Board and Rwanda Ethics Committee approvals. All promoters and CVCT participants provided written informed consent.
Influential network agents who delivered no invitations (N = 56) or who delivered invitations without at least one invited couple seeking testing (N = 11) were excluded from the analysis. The number of invitations, couples tested, and success rates (number of couples tested/number of invitations distributed) were calculated and stratified by INL and INA characteristics and type of couple (cohabiting or noncohabiting) (Table 1). Cohabiting and noncohabiting couples were analyzed separately to identify differences in their receptivity to CVCT, and to examine possible differences in INA-level and invitation-level predictors of successful invitations. Bivariate odds ratios (ORs) and confidence intervals (CIs) were calculated for INL/INA level predictors of couple-testing (Table 2). Bivariate analysis of the association between couple and invitation characteristics and CVCT uptake were performed using generalized estimating equation (GEE) methods to account for two-level clustering within individual INAs and INLs (Table 3).
A multivariable logistic regression model contained INA, couple, and invitation-level characteristics significant in bivariate analyses (Bonferroni P value ≤0.002) or characteristics significant in univariate analyses with scientific rationale for inclusion. Effect measure modification by couple cohabitation status was evaluated. GEE analysis methods with exchangeable correlations accounted for two-level clustering of couple and invitation-level characteristics within individual INAs and INLs (Table 4). Data analysis was performed with SASv9.2 (SAS Insttute Inc., Cary, North Carolina, USA).
Influential network leader characteristics
The average age of INLs was 38 [inter-quartile range (IQR) = 30–45] years, and 73% were men. All INLs were employed, half were homeowners, and they had lived in Kigali for an average of 17 (IQR = 9–28) years. Eighty-one percentage of INLs were married/dating and half had been tested for HIV with their partner. All INLs understood Kinyarwanda, and most understood French and/or English (Table 1).
Influential network agent characteristics and invitation uptake
Influential network agents had an average age of 35 (IQR = 28–40) years and had resided in Kigali for an average of 18 (IQR = 10–26) years. Most were women (70%) and employed in either the sales/service industry or unskilled manual labor. Nearly half were married/dating, and most owned their home and reported testing for HIV alone. The majority understood Kinyarwanda, but most could not understand French and/or English (Table 1).
Influential network agents distributed 24 991 invitations, and 4513 couples sought CVCT as a result of an invitation (18% success rate). INAs distributed an average of 212 invitations resulting in an average of 38 couples tested/INA. Most (60%) invitations were issued to cohabiting couples. The success rate with each group (19% cohabiting vs. 17% noncohabiting) differed by INA characteristics (Table 1).
Faith-based INAs were most successful, distributing the most invitations with the highest success rate (20%). The performance of health network INAs was average in terms of number of invitations and couples tested, but their success rate was substantially higher among cohabiting (21%) vs. noncohabiting (16%) couples. Private-sector INAs were the least successful (Table 2).
Sex, age, duration of residence in Kigali, and relationship status
On average, men distributed more invitations (220) than women (208), but men and women had similar success rates in cohabiting and noncohabiting couples. Increasing INA age was associated with greater success among cohabiting couples, whereas younger INAs had more success among noncohabiting couples. Longer residence in Kigali corresponded with a higher likelihood of success among noncohabiting couples (Table 2). Married/dating INAs had relatively high success rates (Table 1), though this was only significant among noncohabiting couples (Table 2).
Occupation, language skills, and housing
Influential network agents working in agricultural sectors had the highest success rates among both cohabiting and noncohabiting couples (Table 1), whereas unskilled manual laborers had the lowest success rates. INAs in sales/service sectors, professional sectors, and unemployed performed significantly better among noncohabiting couples than unskilled laborers (Table 2). INAs understanding Kinyarwanda had higher success rates (Table 1), but this was significant only in noncohabiting couples (Table 2). Interestingly, INAs understanding French and/or English were more successful among noncohabiting couples but less successful among cohabiting couples. Lastly, INAs owning their homes were less successful, particularly among noncohabiting couples. The importance of a charismatic outlier was observed: the INA living in housing provided by his employer had a success rate of 56% (Table 1).
Previous HIV testing
Only four INAs had never tested for HIV, and they had low average invitations distributed (181) and low average success rate (14%). INAs who tested alone or with their partners were more successful than those who never tested. In stratified analyses, only CVCT remained a significant predictor among noncohabiting couples (Table 2).
Influential network agents with no successful invitations
Eleven INAs delivered no successful invitations. These INAs distributed an average of 201 invitations and were similar to the 118 INAs in the analysis by sex (χ2 = 1.1, P = 0.3), age (F-statistic = 2.3, P = 0.3), and network (χ2 = 1.0, P = 0.8). Given the high likelihood of fraud (i.e. falsely reporting distribution of invitations), these INAs were excluded from analysis.
Couple and invitation characteristics associated with couples’ HIV testing
The mean age of invited men was 31 years and of women was 26 years. Those who tested were slightly older than those who did not. 60% of invited couples were cohabiting and these couples were more likely to seek testing than noncohabiting couples (19 vs. 17%). When INAs invited couples, testing was more likely than inviting women alone (Table 3).
Most contacts were initiated by INAs, though in the rare instances when women initiated contact with INAs, the couple was more likely to test. INAs reported that most invitations were not difficult to deliver (operationalized as time-consuming, requiring long explanations, or challenging because of resistance from the invitee or scheduling conflicts).
Most invitations were issued to people known to the INA in the home or workplace. Being a family member or acquaintance was predictive of CVCT relative to having just met. Invitations distributed in the home were more successful than those distributed in the community. Testing was associated with the invitee having heard public CVCT endorsement prior to invitation and the presence of a mobile testing unit. No differences in success rates were found between the two intervention neighborhoods.
Multivariate model of predictors of couples’ HIV voluntary counseling and testing uptake
We assessed for multicollinearity between variables in the multivariate models. Ages of men and women in couples were collinear, and woman's age was excluded. Effect measure modification by couple cohabitation status was observed, and stratified multivariate models were run. All adjusted odds ratios (aORs) presented in the text below are statistically significant in the multivariate model accounting for two-level clustering (Table 4).
No INA characteristics were statistically significant among all couples, though INAs in the sales/service industry (aOR = 1.6) and unemployed (aOR = 1.7) were more successful among noncohabiting couples. Also among noncohabiting couples, INAs owning a home were less successful (aOR = 0.7) compared with those who rented or had free housing.
Of couple characteristics, older age in men was predictive of increased testing among cohabiting couples (aOR = 1.02/year increase) and decreased testing among noncohabiting couples (aOR = 0.97/year increase). Longer duration of relationship was predictive of CVCT uptake among cohabiting couples (aOR = 1.03/year increase) but with decreased testing among noncohabiting couples (aOR = 0.58/year increase).
Of invitation characteristics, inviting couples vs. individuals was associated with increased testing among cohabiting couples (aOR = 1.2). Cohabiting and noncohabiting couples socially acquainted with the INA were more likely to test (aOR = 1.3 and 1.7, respectively). Invitations delivered in the home vs. other locations predicted testing among cohabiting couples (aOR = 1.3). Invitations accompanied by public endorsements were more successful among cohabiting and noncohabiting couples (aOR = 1.3 and 1.5, respectively), whereas invitations distributed when a mobile testing unit was present were more successful among cohabiting couples (aOR = 1.5).
Promotion of CVCT through influential networks including faith-based, health, private and nongovernmental sectors prompted both cohabiting and noncohabiting couples to seek joint HIV testing. Characteristics of the INA, the invited couple, their relationship, and contextual factors were predictive of successful invitation. INA age, network, occupation, housing, language fluency, marital status, and prior HIV testing were significant predictors of CVCT uptake in crude analyses. Similarly, couple age, cohabitation status, and relationship duration predicted CVCT uptake in crude analyses. Several INA and couple characteristics remained predictive of testing in multivariate analyses. Overall, however, invitation-level contextual characteristics were the most important predictors of couples’ testing, including the relationship of the invitee and INA, place of invitation, delivery of public endorsement, and availability of a mobile testing unit when the invitation was delivered.
The majority of INLs in our study were men, whereas the majority of INAs were women. INLs had high-level positions in society, which in Rwanda are more often occupied by men. Women are less likely to be engaged in full-time employment, and thus more available for person-to-person INA promotional work. Previous studies show effective outreach agents tend to be from the communities they serve, women, and of an acceptable age for the program being implemented [23–26]. INAs in our study worked in their own communities, and though most were women, men and women were equally successful in promoting CVCT.
Not surprisingly, older INAs were more successful among cohabiting couples, whereas younger INAs were more successful among noncohabiting couples. This confirms the value of promotion among age-mates. Among cohabiting couples, if an INA invited both partners together rather than an individual, crude analyses indicate a 20% greater likelihood that the couple would seek testing . Other studies have also shown that targeting couples in HIV/sexually transmitted infection (STI) programs is a successful strategy [19,27,28].
Influential network agents from religious and health networks were more successful in crude analyses relative to private networks, whereas those from nongovernmental or community-based organizations were similar. The importance of community/social network leaders in influencing attitudes and perceptions of HIV risk in sub-Saharan Africa has been reported [29–31]. The ability of religious leaders to promote HIV risk reduction has been explored, and though not significant in our multivariate analysis, was efficacious in promoting AIDS education/prevention in rural Malawi .
Interestingly, INAs understanding French and/or English had increased success among noncohabiting, but decreased success among cohabiting, couples. This may be due to educational differences between older generations, most of whom did not learn French or English in school, and the younger generation who benefited from the introduction of these languages in education curricula after the 1994 genocide.
Older age of couples and longer relationship duration were each independently associated with CVCT uptake among cohabiting couples, indicating couple and relationship maturity increased joint testing. Couples who personally knew the INA, as a social acquaintance or family member, were more likely to test. This confirms the concept embodied in the term ‘influence network’ and that promotions are most successful among people who know and respect the person delivering the message.
Couples were more likely to test if invitations were delivered in the home. Other studies show that VCT/CVCT promotions occurring in couples’ homes and workplaces were more successful relative to community locations in Zimbabwe, Uganda, and Malawi [32–35]. Home-based testing is an extension of that concept [28,33,36,37].
The availability of mobile testing units predicted CVCT in multivariate analysis, indicating they are an acceptable and convenient alternative to permanent sites. The mobile unit brought services closer to beneficiaries, overcoming a major barrier to HIV counseling and testing [36,37].
Invitations preceded by public CVCT endorsements by community leaders were more successful. This finding had been noted in a pilot study of INA promotions  and prompted the addition of INLs to the study design. It is likely that INLs’ senior status enhanced the impact of the promotional model and helped overcome stigma and other cultural and psychosocial barriers.
At the time of this study, though CVCT was not yet standard practice, government antenatal clinics encouraged pregnant women to invite their husbands for testing . Nationwide, the proportion of pregnant women whose partners tested rose from 26 to 33% during this study. There were remarkable differences between health centers, however: in one intervention neighborhood clinic, the proportion of pregnant women whose partners tested was 36% in 2004 and 75% in 2005, whereas in the other, this proportion was 1% in 2004 and 2% in 2005. In the non-intervention neighborhood, 9 and 13% of male partners were tested in 2004 and 2005. We expected spillover of our promotional activities on partner testing in antenatal care clinics, and this may have impacted one intervention neighborhood clinic. Clinic-level determinants – for example the clinic seeing the highest proportion of partners was the first in Kigali to implement prevention of mother to child HIV transmission programs – likely superseded the impact of our community-based promotions. It is important to note that during this time, pregnant women and their partners were not routinely tested together and disclosure was not assured or documented. Though our CVCT advocacy impacted policymakers and funding agencies, counselor training guidelines specifying joint post-test counseling were not publicly available until late 2007 on the Centers for Disease Control and Prevention website and were not adopted by the Government of Rwanda until late 2009.
The overall invitation success rate in this study was 18%, similar to results from other studies. Katz et al.  reported a 16% success rate among women asked to invite partners for counseling and testing after antenatal care visits. CVCT is not yet widely known; many couples do not know discordancy is possible, and stigma and fear of partners’ reaction deter couples from testing . Logistical and cultural barriers must be overcome to establish joint testing as a social norm.
Though CVCT has been shown to reduce HIV transmission, STIs, and unintended pregnancies among couples [9,10,39,40], and despite promising research indicating the efficacy of CVCT promotional activities, widespread implementation of CVCT has not yet occurred in sub-Saharan Africa . Of the 50 million Africans tested for HIV, less than 5% were tested with partners. This number is difficult to estimate because couples’ testing is not among the common Global Fund or PEPFAR indicators.
In this study, a promotional model comprising INLs, INAs, and mobile testing units successfully increased the number of couples accessing CVCT. This successful model may be replicated and adapted to educate and encourage couples to attend CVCT in other countries. Our results highlight practical INA, couple, and invitation characteristics which may be explored as potential predictors of CVCT uptake in different locations. We urge other countries to begin investigating promotional activities to design effective, country-specific CVCT programs to reduce HIV transmission in the highest risk-group in sub-Saharan Africa.
We would like to thank the staff and study participants of the Projet San Francisco for their enthusiasm and invaluable advice. We would also like to thank Drs Joseph Telfair, David L. Roth, and Leslie Clark for their contributions to the development of this intervention. We thank Erin Shutes for the guidance and oversight provided in Kigali during the time of the study, and Suzanne Brownlow for her editorial assistance.
All authors have read and approved the submitted text. Twelve individuals coauthored this manuscript and meet the International Committee of Medical Journal Editors criteria for authorship. Coauthors were integral to the conception, development, implementation, and presentation of this study. Each author's contributions are detailed below.
K.W. contributed to the analysis and interpretation of data; drafted the article and revised it critically for important intellectual content; and gave final approval of the version to be published.
E.K. contributed to the conception and design of the study, revised the article critically for important intellectual content, and gave final approval of the version to be published.
A.N. contributed to the analysis and interpretation of data, revised the article critically for important intellectual content, and gave final approval of the version to be published.
B.B. contributed to the conception of the study and acquisition of data, revised the article critically for important intellectual content, and gave final approval of the version to be published.
G.S. contributed to the conception of the study and acquisition of data, revised the article critically for important intellectual content, and gave final approval of the version to be published.
D.C. contributed to the conception of the study and acquisition of data, revised the article critically for important intellectual content, and gave final approval of the version to be published.
D.J.D. contributed to the conception of the study and acquisition of data, revised the article critically for important intellectual content, and gave final approval of the version to be published.
F.D.C. contributed to the conception of the study and acquisition of data, revised the article critically for important intellectual content, and gave final approval of the version to be published.
E.K. contributed to the conception of the study and acquisition of data, revised the article critically for important intellectual content, and gave final approval of the version to be published.
R.B. contributed to the conception of the study and acquisition of data, revised the article critically for important intellectual content, and gave final approval of the version to be published.
A.T. contributed to the study conception and design, revised the article critically for important intellectual content, and gave final approval of the version to be published.
S.A. contributed to the study design and conception, contributed to the analysis and interpretation of data; revised the article critically for important intellectual content, and gave final approval of the version to be published.
This work was supported by funding from the NIMH RO1 66767, with contribution from the AIDS International Training and Research Program (AITRP) FIC D43 TW001042, the Emory Center for AIDS Research P30 AI050409, R01 AI40951, R01 AI51231, NICHD R01 40125, and the International AIDS Vaccine Initiative.
Conflicts of interest
The authors have no conflicts of interest, including relevant financial interests, activities, relationships, and affiliations.
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