BMC Public Health 2007, 7:349 http://www.biomedcentral.com/1471-2458/7/349 Zambian INAs were more likely than their Rwandan counterparts to identify their faith-based 'hat' as their most prominent role in CVCT promotion. This may be due to the central role that religion plays in Zambian cul- ture [41]. INAs were most effective when addressing couples, a strat- egy that removes the pressure on one spouse to carry the message to the other. Delivering invitations in settings that allowed discreet conversation was important because it allowed fear and stigma to be openly discussed. Fewer than one in ten invitations were delivered in INA homes, but of those one third to one half resulted in couples seek- ing testing. This may also be indicative of the strength of the relationship between the INA and the couple. Loca- tions such as the couples' home and workplace also proved to be more conducive to successful invitation than public locations such as markets, churches, or social gath- erings as noted by others involved in VCT/CVCT research in Zambia, Uganda, and Malawi [15-18] The response rate among couples invited for CVCT by INAs in Kigali was substantially higher than that in Lusaka. Rwandan INAs were more likely to invite people personally known to them, to invite both members of the couple, and to deliver invitations in their own homes than their Zambian colleagues. Invitations in Rwanda were also more likely to be preceded by a public endorsement of CVCT. Other potential explanations for this difference include possible increased receptivity among Rwandan couples, more selective distribution of invitations on the part of Rwandan INAs based on likelihood of attendance, and/or a combination of greater persuasiveness on the part of Rwandan INAs. Factors unrelated to the study no doubt also played a role. Rwandans have one local lan- guage, Kinyarwanda. In comparison, 72 dialects from five major language groups in Zambia are spoken in Lusaka. Kigali is also smaller than Lusaka and transport is easier to organize, which reduced the logistical obstacles to CVCT. Fear of stigma among married couples is common [6,42,43] and was reported by many INAs in the weekly follow-up meetings as an obstacle to their work. Public endorsement of CVCT was used by some INAs to over- come this fear, an effective strategy that addresses psycho- social barriers to accessing clinic services [44]. However, many INAs were reluctant to make public announcements because they had no experience with public speaking and feared being stigmatized themselves. It should also be noted that since more than half of those people being invited to CVCT were known by the INAs, the identifica- tion and training of more INAs over time would be neces- sary in order to have a continued impact throughout the community. Although the results of this study are encouraging, the fact that three-quarters of invited couples in Kigali and nine in ten couples in Lusaka did not seek CVCT confirms that obstacles remain. Lack of time and the money needed for transportation have been cited as obstacles to VCT [12,20] and CVCT [4]. It may be that had the INAs been able to provide home based testing or been accompanied by someone trained to do so, the uptake of CVCT would have been higher. Strategies such as mobile units and decen- tralization of CVCT should be developed to bring services closer to the clients. Conclusion HIV prevention and treatment programs in Africa are receiving an infusion of critical new resources from inter- national donors following exciting developments in antiretroviral therapy and other supportive measures. However, until an effective vaccine and low-cost treat- ment is available to all who need it, the role of prevention cannot be dismissed. During the rapid expansion of peri- natal HIV prevention programs in Africa in the last few years, many thousands of pregnant women were offered VCT and provided with nevirapine. Results from these programs have been discouraging. Researchers and policy makers are advocating for the involvement of men in the treatment process through "PMTCT-Plus" programs that include couple counselling [45] and encourage CVCT before pregnancy in order to safeguard women and improve their outcomes when they do become pregnant [46,47]. Our results demonstrate that the INA model is an effec- tive, sustainable way to promote CVCT in Africa. Influen- tial members of the community are willing and able to inform couples of the benefits of CVCT and invite them to come for services. INAs increase community awareness of CVCT and provide an effective alternative to CWs while educating couples. Predictors of invitation success were similar in the two cities we studied and included strategies that can be easily disseminated in sub-Saharan Africa. Fur- ther research is needed on the role of higher level author- ities in public endorsements and bringing services to couples in the most desirable form. Unless systematic efforts are made to address the social, political and cultural obstacles to CVCT, the gap between research and public health policy and practice will not be bridged. Government and community leaders must endorse CVCT, and service providers must acquire skills to counsel couples. Wherever VCT is provided to cohabiting adults, adding a "C" to VCT will save lives. Competing interests The authors declare that they have no competing interests. Page 8 of 10 (page number not for citation purposes)