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The uptake of HIV testing in
sub-Saharan Africa is influenced by the quality and manner in which health
services are delivered, according to a review of 42 qualitative studies,
published this month in BMC Public Health. Perceived problems with
confidentiality, staff attitudes and long waiting times discouraged many people
from testing, whereas trusted and more convenient facilities – and local
availability of antiretroviral therapy – encouraged individuals to take an HIV
test.
Moreover, the “availability and
convenience of provider-initiated HIV testing provides that extra ‘push’ that
enables individuals to overcome barriers,” the authors write. They call for
stepping up provider-initiated HIV testing, especially when individuals are
being screened for other, less stigmatising, conditions.
Their review also sheds light on
numerous individual and relationship factors that encourage or discourage
people from taking an HIV test.
On average, only four-in-ten African
people living with HIV have been diagnosed. A number of quantitative and
qualitative studies have looked into the reasons why, but systematic reviews
are lacking.
Maurice Musheke and colleagues used
an approach known as ‘meta-ethnography’ to synthesise the results of 42
different qualitative studies conducted in 13 African countries, published
between 2001 and 2012. The researchers were looking specifically for research
on the factors influencing access to and uptake of HIV testing.
They say that despite the diversity
of settings in sub-Saharan Africa, their findings suggest that many of the
barriers and facilitators of HIV testing are similar across the region.
Numerous studies reported that
uptake of testing was influenced by past experiences with health care and trust
in providers. Problems with confidentiality, staff competence and staff
attitudes discouraged people from testing.
“VCT counsellors there know me and
if that counsellor at the VCT [centre] finds me with the virus then he can
start spreading the messages to friends of mine.” (48-year old male, Malawi).
When services had staff who were not
known in the local community, this enhanced perceptions of confidentiality.
When testing was provided at an
HIV-specific health facility, this was often felt to be less confidential. Being
seen at an HIV testing centre was often perceived to be synonymous with sexual
promiscuity and being HIV positive.
Moreover, when taking an HIV test
had financial costs associated with it (user fees, travel expenses, loss of
income), investing in health had to compete with other needs. Inconvenient
testing hours and long waiting times exacerbated such problems.
Some service innovations have
addressed these problems and were reported to have made testing easier.
Outreach mobile and home-based
testing services reduced travel and waiting times. When such services had staff
who were not known in the local community, this enhanced perceptions of
confidentiality.
The abolition of user fees, or the
provision of food and other commodities to people who test, encouraged uptake.
Moreover, the implementation of
‘opt-out’ medical provider initiated testing (especially in antenatal and TB
clinics) had increased the number of people testing. People were already
seeking medical attention and this normalised HIV testing for some. But others
were not sure that they truly had the option to refuse a ‘provider-initiated’
test.
“Although they say its voluntary,
but they put pressure on you to test for it.” (23-year old female tester, South
Africa).
And changes to models of service
delivery may not be enough to counteract deep mistrust of the health system and
conspiratorial beliefs about HIV being a neo-colonial plot.
“Look around you, who is making money off of
this disease? It is not Zambians. It is you [white Westerners]. This is why
people are suspicious of this disease. This is why they think it [AIDS] was
brought in from the outside.” (Elderly male respondent, Zambia).
In some settings, some respondents
believed that HIV testing technologies were unreliable.
The Friends of AIDS Foundation is
dedicated to enhancing the quality of life for HIV positive individuals and
empowering people to make healthy choices to prevent the spread of the HIV
virus. To learn more about The Friends of AIDS Foundation, please visit: http://www.friendsofaids.org.
TOGETHER WE REMAIN STRONG!
