AIDS and Behavior

, Volume 15, Issue 1, pp 1–8 | Cite as

Serosorting and the Evaluation of HIV Testing and Counseling for HIV Prevention in Generalized Epidemics

  • Georges ReniersEmail author
  • Stéphane Helleringer
Editorial Review


UNAIDS and the WHO recognize the importance of HIV Testing and Counseling (HTC) as a gateway to both treatment and prevention [ 1]. Many studies aimed at identifying behavioral changes following HTC have, however, registered only modest reductions in risk behaviors: change—if any—is most commonly reported by women, HIV positives, and in serodiscordant couples. This is also the gist of the review of early studies from predominantly Europe and North America [ 2, 3, 4], and a review of seven studies set in developing countries [ 5]. More recent studies from sub-Saharan Africa, summarized in Table  1, largely corroborate these conclusions. The most ambitious HTC impact evaluation studies target reductions in HIV incidence, but none have been detected so far [ 6, 7, 8]. In serodiscordant couples, however, HTC is associated with a reduction in HIV transmission [ 9].
Table 1

Description of selected HTC efficacy studies in sub-Saharan Africa and their main findings

Study, Year




Sexual Partnership Serodiscordant Couple Partner Characteristic Generalize Epidemic Seroadaptive Behavior 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Susan Watkins and the journal’s reviewers for their comments and suggestions.


  1. 1.
    UNAIDS/WHO. UNAIDS/WHO Policy Statement on HIV Testing. 2004. Accessed 24 June 2009.
  2. 2.
    Higgins DL, Galavotti C, O’Reilly KR, Schnell DJ, Moore M, Rugg DL, et al. Evidence for the effects of HIV antibody counseling and testing on risk behaviors. JAMA. 1991;266(17):2419–29.CrossRefPubMedGoogle Scholar
  3. 3.
    Wolitski RJ, MacGowan RJ, Higgins DL, Jorgensen CM. The effects of HIV counseling and testing on risk-related practices and help-seeking behavior. AIDS Educ Prev. 1997;9(3 S):52–67.PubMedGoogle Scholar
  4. 4.
    Weinhardt LS, Carey MP, Johnson BT, Bickham NL. Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 1985–1997. Am J Public Health. 1999;89(9):1397–405.CrossRefPubMedGoogle Scholar
  5. 5.
    Denison JA, O’Reilly KR, Schmid GP, Kennedy CE, Sweat MD. HIV voluntary counseling and testing and behavioral risk reduction in developing countries: a meta-analysis, 1990–2005. AIDS Behav. 2008;12(3):363–73.CrossRefPubMedGoogle Scholar
  6. 6.
    Corbett EL, Makamure B, Cheung YB, Dauya E, Matambo R, Bandason T, et al. HIV incidence during a cluster-randomized trial of two strategies providing voluntary counselling and testing at the workplace, Zimbabwe. AIDS. 2007;21(4):483–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Matovu JK, Gray RH, Makumbi F, Wawer MJ, Serwadda D, Kigozi G, et al. Voluntary HIV counseling and testing acceptance, sexual risk behavior and HIV incidence in Rakai, Uganda. AIDS. 2005;19(5):503–11.CrossRefPubMedGoogle Scholar
  8. 8.
    Sherr L, Lopman B, Kakowa M, Dube S, Chawira G, Nyamukapa C, et al. Voluntary counselling and testing: uptake, impact on sexual behaviour, and HIV incidence in a rural Zimbabwean cohort. AIDS. 2007;21(7):851–60.CrossRefPubMedGoogle Scholar
  9. 9.
    Allen S, Tice J, Van de Perre P, Serufilira A, Hudes E, Nsengumuremyi F, et al. Effect of serotesting with counselling on condom use and seroconversion among HIV discordant couples in Africa. Br Med J. 1992;304(6842):1605–9.CrossRefGoogle Scholar
  10. 10.
    Glick P. Scaling up HIV voluntary counseling and testing in Africa: what can evaluation studies tell us about potential prevention impacts? Eval Rev. 2005;29(4):331–57.CrossRefPubMedGoogle Scholar
  11. 11.
    Shelton JD. Counselling and testing for HIV prevention. Lancet. 2008;372(9635):273–5.CrossRefPubMedGoogle Scholar
  12. 12.
    Reniers G. Marital strategies for regulating exposure to HIV. Demography. 2008;45(2):417–38.CrossRefPubMedGoogle Scholar
  13. 13.
    Watkins SC. Navigating the AIDS epidemic in rural Malawi. Popul Dev Rev. 2004;30(4):673–705.CrossRefGoogle Scholar
  14. 14.
    Porter L, Hao L, Bishai D, Serwadda D, Wawer MJ, Lutalo T, et al. HIV status and union dissolution in sub-Saharan Africa: the case of Rakai, Uganda. Demography. 2004;41(3):465–82.CrossRefPubMedGoogle Scholar
  15. 15.
    Zulu EM, Chepngeno G. Spousal communication about the risk of contracting HIV/AIDS in rural Malawi. Demogr Res. 2003;S1:247–78.CrossRefGoogle Scholar
  16. 16.
    Gregson S, Zhuwau T, Anderson RM, Chandiwana SK. Is there evidence for behaviour change in response to AIDS in rural Zimbabwe? Soc Sci Med. 1998;46(3):321–30.CrossRefPubMedGoogle Scholar
  17. 17.
    Donovan B. The repertoire of human efforts to avoid sexually transmissible diseases: past and present. Part 1: strategies used before or instead of sex. Sex Transm Infect. 2000;76(1):7–12.CrossRefPubMedGoogle Scholar
  18. 18.
    Suarez T, Miller J. Negotiating risks in context: a perspective on unprotected anal intercourse and barebacking among men who have sex with men—where do we go from here? Arch Sex Behav. 2001;30(3):287–300.CrossRefPubMedGoogle Scholar
  19. 19.
    Parsons JT, Schrimshaw EW, Wolitski RJ, Halkitis PN, Purcell DW, Hoff CC, et al. Sexual harm reduction practices of HIV-seropositive gay and bisexual men: serosorting, strategic positioning, and withdrawal before ejaculation. AIDS. 2005;19(S1):S13–25.CrossRefPubMedGoogle Scholar
  20. 20.
    Cox J, Beauchemin J, Allard R. HIV status of sexual partners is more important than antiretroviral treatment related perceptions for risk taking by HIV positive MSM in Montreal, Canada. Sex Transm Infect. 2004;80(6):518–23.CrossRefPubMedGoogle Scholar
  21. 21.
    Snowden J, Raymond HF, McFarland W. Prevalence of seroadaptive behaviors of men who have sex with men, San Francisco, 2004. Sex Transm Infect. 2009;85(6):469–76.CrossRefPubMedGoogle Scholar
  22. 22.
    Pinkerton SD. Acute HIV infection increases the dangers of serosorting. Am J Prev Med. 2008;35(2):184.CrossRefPubMedGoogle Scholar
  23. 23.
    Eaton LA, Kalichman SC, Cain DN, Cherry C, Stearns HL, Amaral CM, et al. Serosorting sexual partners and risk for HIV among men who have sex with men. Am J Prev Med. 2007;33(6):479–85.CrossRefPubMedGoogle Scholar
  24. 24.
    Wilson DP, Regan DG, Heymer KJ, Jin F, Prestage GP, Grulich AE. Serosorting may increase the risk of HIV acquisition among men who have sex with men. Sex Transm Dis. 2010;37(1):13–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Butler DM, Smith DM. Serosorting can potentially increase HIV transmissions. AIDS. 2007;21(9):1218–20.CrossRefPubMedGoogle Scholar
  26. 26.
    Poudel KC, Poudel-Tandukar K, Yasuoka J, Jimba M. HIV superinfection: another reason to avoid serosorting practice. Lancet. 2007;370(9581):23.CrossRefPubMedGoogle Scholar
  27. 27.
    Cassels S, Menza TW, Goodreau SM, Golden MR. HIV serosorting as a harm reduction strategy: evidence from Seattle, Washington. AIDS. 2009;23(18):2497–506.CrossRefPubMedGoogle Scholar
  28. 28.
    Jin F, Crawford J, Prestage GP, Zablotska I, Imrie J, Kippax SC, et al. Unprotected anal intercourse, risk reduction behaviours, and subsequent HIV infection in a cohort of homosexual men. AIDS. 2009;23(2):243–52.CrossRefPubMedGoogle Scholar
  29. 29.
    Truong HM, Kellogg T, Klausner JD, Katz MH, Dilley J, Knapper K, et al. Increases in sexually transmitted infections and sexual risk behaviour without a concurrent increase in HIV incidence among men who have sex with men in San Francisco: a suggestion of HIV serosorting? Sex Transm Infect. 2006;82(6):461–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Golden MR, Stekler J, Hughes JP, Wood RW. HIV serosorting in men who have sex with men: is it safe? J Acquir Immune Defic Syndr. 2008;49(2):212–8.CrossRefPubMedGoogle Scholar
  31. 31.
    BBC. Love aid for Ethiopians with AIDS. 2003. Accessed 24 June 2009.
  32. 32.
    BBC. India HIV couples to tie the knot. 2006. Accessed 24 June 2009.
  33. 33.
    IRIN. Kenya: where only HIV-positive people get beyond the velvet rope. 2008. Accessed 24 June 2009.
  34. 34.
    BBC. HIV-positive Zimbabweans find love. 2006. Accessed 26 Jul 2009.
  35. 35.
    Economist. Positive dating: HIV sufferers find love online. 12 Oct 2006.Google Scholar
  36. 36.
    Rhine K. Support groups, marriage, and the management of ambiguity among HIV positive women in northern Nigeria. Anthropol Q. 2009;23(2):369–400.CrossRefGoogle Scholar
  37. 37.
    Seeley J, Russell S, Khana K, Ezati E, King R, Bunnell R. Sex after ART: sexual partnerships established by HIV-infected persons taking anti-retroviral therapy in eastern Uganda. Cult Health Sex. 2009;11(7):703–16.CrossRefPubMedGoogle Scholar
  38. 38.
    Kabiru CW, Luke N, Izugbara CO, Zulu EM. The correlates of HIV testing and impacts on sexual behavior: evidence from a life history study of young people in Kisumu, Kenya. BMC Public Health. 2010;10(1):412.CrossRefPubMedGoogle Scholar
  39. 39.
    Uneke CJ, Alo M, Ogbu O. Mandatory pre-marital HIV testing in Nigeria: the public health and social implications. AIDS Care. 2007;19(1):116–21.CrossRefPubMedGoogle Scholar
  40. 40.
    Rennie S, Mupenda B. Ethics of mandatory premarital HIV testing in Africa: the case of Goma, Democratic Republic of Congo. Dev World Bioeth. 2008;8(2):126–37.CrossRefPubMedGoogle Scholar
  41. 41.
    IRIN. Nigeria: “With this HIV test, I thee wed”. 2008. Accessed 22 Dec 2009.
  42. 42.
    Frost DM, Stirratt MJ, Ouellette SC. Understanding why gay men seek HIV-seroconcordant partners: intimacy and risk reduction motivations. Cult Health Sex. 2008;10(5):513–27.CrossRefPubMedGoogle Scholar
  43. 43.
    Tavory I, Swidler A. Condom semiotics: meaning and condom use in rural Malawi. Am Soc Rev. 2009;74(2):171–89.CrossRefGoogle Scholar
  44. 44.
    Chimbiri AM. The condom is an ‘intruder’ in marriage: evidence from rural Malawi. Soc Sci Med. 2007;64(5):1102–15.CrossRefPubMedGoogle Scholar
  45. 45.
    Medley A, Garcia-Moreno C, McGill S, Maman S. Rates, barriers and outcomes of HIV serostatus disclosure among women in developing countries: implications for prevention of mother-to-child transmission programmes. Bull World Health Organ. 2004;82(4):299–307.PubMedGoogle Scholar
  46. 46.
    MoHSS, Macro International Inc. Demographic and Health Survey 2006–07. Windhoek, Namibia and Calverton, MD, USA: Ministry of Health and Social Services and Macro International Inc.; 2008.Google Scholar
  47. 47.
    CSO [Swaziland], Macro International Inc. Swaziland Demographic and Health Survey 2006–07. Mbabane, Swaziland: Central Statistical Office and Macro International Inc.; 2008.Google Scholar
  48. 48.
    CSO [Zambia], MOH, TDRC, University of Zambia, Macro International Inc. Zambia Demographic and Health Survey 2007. Calverton, MD, USA: Central Statistical Office and Macro International Inc.; 2009.Google Scholar
  49. 49.
    Van der Bij AK, Kolader ME, de Vries HJC, Prins M, Coutinho RA, Dukers NH. Condom use rather than serosorting explains differences in HIV incidence among men who have sex with men. J Acquir Immune Defic Syndr. 2007;45(5):574–80.CrossRefPubMedGoogle Scholar
  50. 50.
    Allen S, Meinzen-Derr J, Kautzman M, Zulu I, Trask S, Fideli U, et al. Sexual behavior of HIV discordant couples after HIV counseling and testing. AIDS. 2003;17(5):733–40.CrossRefPubMedGoogle Scholar
  51. 51.
    The Voluntary HIV-1 Counselling and Testing Efficacy Study Group. Efficacy of voluntary HIV-1 counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomised trial. The Voluntary HIV-1 Counseling and Testing Efficacy Study Group. Lancet. 2000;356(9224):103–12.Google Scholar
  52. 52.
    Warner L, Newman DR, Austin HD, Kamb ML, Douglas JM Jr, Malotte CK, et al. Condom effectiveness for reducing transmission of gonorrhea and chlamydia: the importance of assessing partner infection status. Am J Epidemiol. 2004;159(3):242–51.CrossRefPubMedGoogle Scholar
  53. 53.
    Helleringer S, Reniers G. Study designs fail to represent the intricate effects of HIV testing and counselling on condom use and HIV transmission in sub-Saharan Africa. Int J Epidemiol. 2010. doi: 10.1093/ije/dyq075.
  54. 54.
    Hudgens MG, Halloran ME. Toward causal inference with interference. J Am Stat Assoc. 2008;103(482):832–42.CrossRefPubMedGoogle Scholar
  55. 55.
    Khumalo-Sakutukwa G, Morin SF, Fritz K, Charlebois ED, van Rooyen H, Chingono A, et al. Project Accept (HPTN 043): a community-based intervention to reduce HIV incidence in populations at risk for HIV in sub-Saharan Africa and Thailand. J Acquir Immune Defic Syndr. 2008;49(4):422–31.CrossRefPubMedGoogle Scholar
  56. 56.
    Kippax S, Race K. Sustaining safe practice: twenty years on. Soc Sci Med. 2003;57(1):1–12.CrossRefPubMedGoogle Scholar
  57. 57.
    Roth DL, Stewart KE, Clay OJ, van Der Straten A, Karita E, Allen S. Sexual practices of HIV discordant and concordant couples in Rwanda: effects of a testing and counselling programme for men. Int J STD AIDS. 2001;12(3):181–8.CrossRefPubMedGoogle Scholar
  58. 58.
    Matovu JK, Gray RH, Kiwanuka N, Kigozi G, Wabwire-Mangen F, Nalugoda F, et al. Repeat voluntary HIV counseling and testing (VCT), sexual risk behavior and HIV incidence in Rakai, Uganda. AIDS Behav. 2007;11(1):71–8.CrossRefPubMedGoogle Scholar
  59. 59.
    Mola OD, Mercer MA, Asghar RJ, Gimbel-Sherr KH, Gimbel-Sherr S, Micek MA, et al. Condom use after voluntary counselling and testing in central Mozambique. Trop Med Int Health. 2006;11(2):176–81.CrossRefPubMedGoogle Scholar
  60. 60.
    Arthur G, Nduba V, Forsythe S, Mutemi R, Odhiambo J, Gilks C. Behaviour change in clients of health centre-based voluntary HIV counselling and testing services in Kenya. Sex Transm Infect. 2007;83(7):541–6.CrossRefPubMedGoogle Scholar
  61. 61.
    Cremin I, Nyamukapa C, Sherr L, Hallett TB, Chawira G, Cauchemez S, et al. Patterns of self-reported behaviour change associated with receiving voluntary counselling and testing in a longitudinal study from Manicaland, Zimbabwe. AIDS Behav. 2010;14(3):708–15.CrossRefPubMedGoogle Scholar
  62. 62.
    Huchko MJ, Montandon M, Nguti R, Bukusi EA, Cohen CR. The association of HIV counseling and testing with HIV risk behaviors in a random population-based survey in Kisumu, Kenya. AIDS Behav. 2009. doi: 10.1007/s10461-009-9649-4.
  63. 63.
    Turner AN, Miller WC, Padian NS, Kaufman JS, Behets FM, Chipato T, et al. Unprotected sex following HIV testing among women in Uganda and Zimbabwe: short- and long-term comparisons with pre-test behaviour. Int J Epidemiol. 2009;38(4):997–1007.CrossRefPubMedGoogle Scholar
  64. 64.
    Kalichman SC, Cain D, Simbayi LC. Behavioral changes associated with testing HIV-positive among sexually transmitted infection clinic patients in Cape Town, South Africa. Am J Public Health. 2010;100(4):714–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Office of Population Research and Department of SociologyPrinceton UniversityPrincetonUSA
  2. 2.Mailman School of Public Health and Columbia Population Research Center, Columbia UniversityNew YorkUSA

Personalised recommendations