Scale up of HIV testing in Africa isn't leading to breaches in consent or confidentiality

Efforts to scale up HIV testing in sub-Saharan Africa have not resulted in breaches of patient rights or the provision of poorer services, results of a study published in PLoS Medicine suggest.

The authors examined whether practices relating to consent, confidentiality and referral to HIV care differed between traditional voluntary counselling and testing (VCT) facilities and centres where testing was initiated by healthcare providers.

“The rights of clients, particularly regarding informed consent and confidentiality, can be protected even as testing is scaled up at health facilities,” write the investigators.

VCT has long been the cornerstone of HIV testing. At its core are the principles of informed consent and confidentiality.

However, the large prevalence of undiagnosed HIV infections means that alternative methods of HIV testing are being explored. This includes provider-initiated testing. Guidelines have been developed by the World Health Organization to ensure that these services are based on informed consent, confidentiality and respect patient rights.

Investigators from the MATCH (Multi-Country African Testing and Counseling for HIV) study wanted to see how VCT and provider-initiated services compared in terms of consent, counselling and, in the case of patients testing positive, onward referral to HIV care.

Their research was conducted between 2007 and 2008 and involved facilities in Burkina Faso, Kenya, Malawi and Uganda.

The investigators compared the experiences of HIV testing between three types of healthcare facilities:

• Integrated testing facilities – these offered provider-initiated testing, patient-initiated testing and other medical services.
• Stand alone VCT facilities.
• Prevention of mother-to-child transmission testing at facilities offering care to pregnant women.

A total of 2116 people were interviewed about their experiences of testing at these facilities. The questions focused on several key outcome measures:

• Provision of pre- and post-test counselling.
• Consent.
• Confidentiality.
• Provision of information.
• Overall level of treatment.
• Provision of results.
• Referral if HIV positive.

Taken as a whole, the results were very good. A high proportion of people (83%) met with a counsellor before testing; 90% of patients reported that they had given consent; 99% were provided with their test results and 74% of patients received an appropriate onward referral.

However, there were differences in outcomes between the services.

People who had an HIV test at integrated centres were less likely to see a counsellor than those who tested using VCT services (83 vs 95%, p < 0.001). However, patients at integrated centres who did meet with a counsellor were more likely to complete consent procedures than individuals at VCT centres (89 vs 83%, p < 0.001) and also to complete pre-test counselling (78 vs 73%, p = 0.015).

Users of integrated and prevention of mother-to-child transmission services were more likely to receive post-test counselling than people tested via VCT (59 vs 36%, p < 0.001).

Analysis by country also revealed some significant differences in experience between the types of testing facility.

For instance, in Burkina Faso people testing at integrated centres were less likely to meet with a counsellor before their test (67 vs 96% VCT users, p < 0.001) or be satisfied with post-test counselling (62 vs 77% VCT users).

However, in Malawi, VCT users were less likely to receive full post-test counselling than either prevention of mother-to-child transmission service users or those tested at integrated facilities (54 vs 75 vs 71%, p = 0.023).

Analysis of pooled data from all four countries showed that use of VCT services increased the likelihood of seeing a counsellor by a fifth (APR = 1.22; 95% CI, 1.07-1.38) compared with integrated facilities. There was also higher satisfaction with VCT than integrated testing (APR = 1.15; 95% CI, 1.06-1.25).

Nevertheless, the investigators were encouraged by their findings: “A major result of this analysis is that across all countries and modes of testing, high percentages of clients reported having received services around testing that are considered important in most guidelines…services around testing do not seem to be associated with major breaches of autonomy or privacy.”

They highlight “some significant associations between outcome measures and mode of testing, but differences across modes of testing were not consistent with the notion that one mode of testing performs better than the others.”

The authors therefore believe their results “provide some reassurance that the efforts to provide HIV testing in different countries through different approaches can help knowledge of HIV status and referral to appropriate care.”

Obermeyer CM Associations between mode of HIV testing and consent, confidentiality, and referral: a comparative analysis in four African countries. PLoS Medicine 9 (10): e1001329.