Table 2.

Strategic framework for improving VCT accessibility and acceptability.

Strategy	Justification	Key findings that support the strategy	Recommendations for service delivery (practice)
(1) Improve advocacy for VCT among leaders	(i) Advocacy is likely to increase the volume and quality of VCT services (ii) Involvement of local leaders in VCT programmes is important (iii) Advocacy of relevant key stakeholders is likely to generate support and funding for VCT services	(i) VCT managers indicated limited resources for VCT services and yet they believe if VCT are prioritised, there is likely to be financial support (ii) Respondents indicated the significant role their local leader could play in increasing VCT accessibility (iii) VCT managers indicated that sometimes there is poor response in community VCT due to poor mobilisation	(i) There is a need to understand the appropriate medium of communication for different stakeholders (ii) Hospitals should conduct promotional campaigns for counselling and testing aimed at raising support for VCT services (iii) Strong advocacy and synergising strategic approaches and efforts of various sectors, including the media, should be designed and implemented (iv) Health workers need to be trained in advocacy skills
(2) Increase awareness and mobilise communities	(i) Awareness of VCT services and the benefits of testing is a major factor in accessing and using the services (ii) When communities are mobilised, it enables the members to make informed decisions about VCT utilisation (iii) Talking freely about HIV AIDS reduces stigma and increases chances of testing	(i) Among the Kasenyi respondents, 23.6% thought that people could tell HIV status without necessarily testing (ii) Findings from respondents in phase I indicate that 27.6% are not aware of VCT services (iii) 11% did not know where to access VCT services (iv) If well mobilised, 89.8% of the respondents said it would be easy for them to go for an HIV test (v) VCT managers indicated that advertising for VCT services is limited, relying only on word of mouth (vi) Radio is listened to by 83.5% of participants at Kasenyi, thus good media (vii) 56.7% indicated fear of HIV results as a major barrier to testing (viii) 60% of respondents had not heard any message about VCT in the last 3 months (ix) Discussing issues related to HIV was found to be associated with HIV testing, as 96.7% of respondents who had tested had discussed HIV issues with someone	(i) Communities should continuously be given enough information so as to see VCT as a norm, which will reduce fear for HIV testing, reduce stigma, and increase the uptake of the services (ii) The use of radio in transmitting VCT messages would be the best medium of communication for the Kasenyi fish landing community (iii) It is important to encourage community members to talk about HIV in general and VCT in particular as it is likely to lead to testing (iv) Involve individuals in the target communities in the planning and implementation of VCT services
(3) Promote provider- initiated HIV counselling and testing	(i) It is a basic responsibility of health care providers to recommend HIV testing and counselling as part of routine clinical management (ii)  Patients attending hospitals for health services could decide to take a test if health providers inform them about it	(i) According to the VCT managers, mothers coming for antenatal services are told of VCT services, and the majority accept and they are tested (ii) Findings from the Kasenyi respondents indicated that 25% of those who had tested had been asked to, but were happy to have tested (iii) VCT managers indicated that provider-initiated HIV testing and counselling is recommended as long as it is voluntary and follows principles of informed consent, counselling and confidentiality	(i) Whenever individuals attend a health centre, whether seeking health services or escorting a patient, they should be informed of the availability of VCT services and the importance of testing for HIV (ii) Whether an HIV test is requested by a health provider or not, pretest counselling should always be provided and confidentiality ensured
(4) Create an environment conducive to clients seeking VCT services	(i) Individuals are more likely to demand VCT services on their own if there is an enabling, favourable environment (ii) If potential clients are assured of privacy and confidentiality, the utilisation of VCT services is likely to increase	(i) There is a positive attitude towards testing. Of the Kasenyi respondents, 97.6% indicated that VCT is a good service (ii) There is a need to create a favourable environment. For example, some of the Kasenyi respondents emphasised the need for privacy and confidentiality in testing (iii) At testing sites, VCT counsellors indicated their efforts to making VCT service responsive to client and community needs and priorities	(i) There is a need to improve other health services as well, not just VCT services (ii) Mobile VCT services should be considered for special populations such as people in remote rural areas and without access to health services, so as to make it easy for them to access VCT services (iii) Assurances of privacy and confidentiality as well as trustworthiness are key factors in individuals' decision to test (iv) Testing should be voluntary and routinely offered to clients rather than clients having to request it
(5) Explore other VCT staffing alternatives	(i) Lack of adequate and well-trained VCT personnel is a major challenge in health services delivery (ii) VCT clients do not like spending unnecessary time at VCT sites	(i) VCT managers and counsellors indicated that the integration of VCT services with other services without additional staff has created staff shortages (ii) VCT staffing shortages were evident, when VCT counsellors and managers indicated that they prioritise emergencies, and VCT is not an emergency (iii) VCT counsellors indicated that community members could be trained to at least offer precounselling services in their communities (iv) The availability of averagely educated residents at Kasenyi could be a potential for working as community volunteer counsellors (v) Limited staff means more time clients spend at VCT sites. For example, 30% of respondents did not like the long time they spent at VCT sites	(i) With limited funding, use of community volunteers could be considered as an option (ii) Community volunteer counsellors could be a cheaper alternative source for the much needed human resources (iii) Great care needs to be taken while selecting community volunteers to ensure that they will be accepted in their communities
(6) Progressive monitoring of VCT services	(i) The best way to understand and improve the quality of VCT is to continuously assess the services (ii) Collection of essential basic data is one of the ways of assessing the performance of VCT services (iii) When funds are limited, as in this case, monitoring does not need to be massive and expensive, but just collection of basic data	(i) Collection of basic statistics on VCT services utilisation was not done at VCT sites (ii) Client satisfaction assessments as a means of improving VCT quality are not often done (iii) Some respondents who had accessed VCT services were not happy with certain elements of VCT services, such as too much time spent at the site (iv) Counsellor support supervision was noted to be missing at the VCT sites	(i) Support supervision and giving immediate feedback to VCT counsellors is of great value (ii) Periodic client satisfaction should be evaluated to match the needs and requirements of the VCT clients (iii) Counsellors should be interested in learning new counselling skills, be comfortable in discussing specific-HIV risk behaviours, and receive periodic support supervision (iv) Simple methods of monitoring VCT service delivery such as exit interviews or suggestion boxes could be used