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
VCT has long been the
cornerstone of HIV testing. At its core are the principles of informed consent
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
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
Their research was
conducted between 2007 and 2008 and involved facilities in Burkina Faso, Kenya,
Malawi and Uganda.
compared the experiences of HIV testing between three types of healthcare
- 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.
- 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 <
Analysis by country
also revealed some significant differences in experience between the types of
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).
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.”