Nearly 1 million Ethiopians are infected with HIV, and 60 percent of these individuals are women. Ethiopia is rapidly expanding voluntary HIV counseling and testing (VCT) services and has made increased testing rates among women an important programmatic goal. Very little is known about how many people test repeatedly for HIV or their motivations for doing so. In particular, the relationship between perceived risk and HIV testing behavior is not well understood. This study was conducted with 2,027 women attending eight public sector Ethiopian VCT facilities. Mixed methods were used to develop two measures for personal perceptions of HIV risk: perceived risk and perceived vulnerability.

We conducted 44 in-depth interviews with VCT clients to better understand women's self-assessed HIV risk. Women expressed HIV risk in terms of vulnerability, often describing risk as something that has "happened" to them. In part, these women were testing in response to felt susceptibility to HIV infection due to circumstantial surroundings or improbable non-sexual modes of transmission.

Psychometric scales were developed to measure perceived HIV behavioral risk and perceived HIV vulnerability. Based on findings from the in-depth interviews, the scales were revised and tested among a sample of 200 women. The scales demonstrated higher internal reliability in the validation sample. Cronbach's alpha for the perceived vulnerability scale increased from 0.66 to 0.74.

Last, women who have tested previously for HIV are compared to first-time testers in terms of demographic, cognitive, behavioral and psychosocial characteristics. Nearly 40 percent of women had tested previously for HIV. Repeat HIV testing was associated with more self-reported risk behavior. Moderate perceived vulnerability is associated with a 50 percent increase in the likelihood of repeat HIV testing, while having a high level of perceived HIV risk is associated with a 40 percent decrease in the likelihood that a woman will be a repeat tester.

VCT messaging should be re-directed toward individuals with risk behavior for optimal resource allocation. Self-reported risk behavior was significantly higher among repeat testers compared to first-time testers. Thus, improved risk reduction counseling messages are also needed in this setting, particularly for repeat HIV testers.