BMC Public Health 2007, 7:349 http://www.biomedcentral.com/1471-2458/7/349 Background In 2006 more than 65% of the 4.3 million new cases of HIV occurred in Sub-Saharan Africa [1]. In this region, most transmission is heterosexual, occurring predomi- nately between cohabiting partners [2]. Among pregnant women tested with their partners in antenatal clinics in Lusaka, the capital of Zambia, 19% of couples had two HIV+ partners ("concordant +") and 17% had one HIV+ and one HIV- partner ("discordant"). In Kigali, the capital of Rwanda, 8% of couples were concordant + and 9% were discordant [3]. These results are similar to those reported in couples' voluntary HIV counselling and test- ing (CVCT) centres [4-7], cluster sampling surveys [8], and to those reported for couples in neighbouring Kenya and Tanzania [9]. Cohabiting couples in Africa now represent the world's largest HIV risk group [10,11]. VCT is a cost-effective method of reducing HIV transmission [12-14] and tradi- tional clinic-based services have recently expanded to include home based, workplace and mobile counselling strategies [13,15-20]. Though VCT is particularly effective when partners are tested together, joint testing remains rare in Africa. Promotional strategies, including door-to- door outreach by community workers and weekend CVCT services in antenatal clinics, have been shown to increase the number of couples tested [3-5,15]. While these efforts show that CVCT can be de-centralized and implemented in a variety of settings, they have not proven to be sustain- able after research funding has ended. Several factors affect demand for and supply of CVCT. Demand for CVCT is low because of the belief that monogamy is 'safe', fear of stigma, gender inequality, and lack of knowledge of the availability of CVCT [4,6,21-23]. Given the low demand, policymakers and other influen- tial groups have not promoted CVCT. In turn, funding agencies have not supported CVCT services, further com- promising supply and ensuring low utilization. Given what we know about the beneficial impact of CVCT [24], it is critical that this continuing cycle of low demand and low supply be interrupted [11]. The importance of social networks and community leader involvement in changing attitudes towards HIV/AIDS has been shown to have significant impact on risk perception among individuals in Southern Africa [25-27]. We present here the results of an intervention using influential people to overcome ignorance and stigma, establish the impor- tance of being tested as couples, and invite couples to attend CVCT services in two African capital cities, Kigali, Rwanda and Lusaka, Zambia. Methods The study was initiated by the Rwanda Zambia HIV Research Group (RZHRG), in collaboration with the Min- istry of Health Treatment and Research AIDS Centre (TRAC) in Rwanda and the University Teaching Hospital (UTH) in Zambia and approved by Institutional Review Boards in Rwanda, Zambia, and the US. The components of the intervention included recruitment and training of Influence Network Agents (INAs) to promote CVCT, and provision of CVCT services at stand-alone RZHRG facili- ties. The study took place from January to July, 2003. Recruitment and training of INAs RZHRG staff and collaborators at UTH and TRAC identi- fied and referred candidate INAs considered influential in the communities near the CVCT centres. A four-day train- ing began with orientation including observation of the CVCT process and a demonstration of door-to-door pro- motion by project community workers (CWs). Given that INAs might be reluctant to be tested by colleagues, testing for HIV was offered but not required as part of training. Standard operating procedures (SOPs) were developed to guide all INA related training and outreach activities. INAs then completed a demographic questionnaire, partici- pated in focus groups with 4–8 other INAs, and attended formal didactic training on HIV, CVCT, outreach skills, and the logistics of invitation distribution and data collec- tion. Each INA was asked to choose the category that best described their role when distributing invitations: health care, religious, non-governmental/community-based organization (NGO/CBO), or private sector. While the recruitment goal was to have roughly equal numbers of INAs in each of the four categories, individual INAs may have identified more strongly with a role other than the one they were recruited in. For example a business owner may have also been a church elder and may have felt that the latter role would be more important when promoting CVCT. INA data collection Invitations distributed to couples described the location of the centre and CVCT procedures. Each invitation was identified by a numeric code including a unique INA identifier and an invitation number. A corresponding "invitation receipt" with the same numeric code allowed the INA to record basic demographic data about the invited couples, including age of man and woman, dura- tion of cohabitation, number of children, and residential neighbourhood. No names or couple identifiers were recorded. INAs also recorded date and time of the invita- tion; location (couple home, INA home, workplace, com- munity); the relationship of the INA to the invitee (family member, friend, professional or social contact, or just met/unknown); who received the invitation (couple, man, woman); and whether the invitation was preceded Page 2 of 10 (page number not for citation purposes)