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.
Health services – quality, trust and access
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.
Beliefs about risk of infection and health
Studies reported that individuals were motivated to test or decided it was unnecessary, based on their own assessment of their risk of infection.
Having poor health oneself, or a sexual partner or child being in poor health, raised many people’s perception of risk. Sometimes having had multiple sexual partners or believing a partner to have been unfaithful also created a sense of vulnerability.
Such experiences motivated many to test, but paradoxically, some who assumed that they were infected did not feel the need to confirm this with a test.
A recurring theme of studies was individuals not testing for HIV because they perceived themselves to be at low risk of infection. This was sometimes motivated by low levels of sexual activity or a perception that HIV was primarily an issue for sex workers.
Others did not feel the need to test because their partner was reported to be HIV-negative, because they trusted their partner, or because they did not have any symptoms of ill-health.
The researchers call for sensitisation campaigns to focus on the way individuals assess their own risk, especially when HIV is understood as a far-off threat.
The increasing availability of antiretroviral treatment encouraged many people to test.
People’s beliefs and understandings of health – and what it means to live with diagnosed HIV – influenced decisions about testing. Even when antiretroviral treatment was available, having diagnosed HIV was still associated with death and mental distress, with a diagnosis causing an individual to ‘think too much’.
“Why look for troubles – I will never do a test. I cannot look for my death.” (Male non-tester, Tanzania).
Nonetheless, numerous studies found that the increasing availability of antiretroviral treatment – with HIV no longer being seen as a death sentence – encouraged many people to test. Specifically, pregnant women were aware of having a means to prevent onward transmission should they be diagnosed with HIV.
Several studies reported that fears of being stigmatised discouraged people from testing.
“Even if I am already infected, nobody knows and it causes me no problems, at least for now. Imagine I go and do the testing and I find out I am positive, for how long will I hide it? Once people get to know I will be finished. My family will shun me. My friends will desert me. I will not be able to get a decent job. That is dying even before the infection kills me.” (25-year old female non-tester, Nigeria).
Individuals feared losing sexual partners and social support if they tested – divorce and domestic violence were seen as possible consequences. Single people were concerned that they would not be able to marry in the future.
Social expectations in relation to key life events, especially marriage and parenthood, could encourage HIV testing.
In particular, numerous studies found that married women lacked autonomy in relation to HIV testing and their health more broadly. Women needed permission from husbands to test, but requesting it could raise suspicions of infidelity or accusations of having brought HIV into the couple. Frequently, HIV testing was shunned to avoid straining the marriage.
The authors note that in societies which lack formal welfare systems, people rely on family and social connections for survival. The withdrawal of material and social support could have profound consequences.
Conversely, when people did choose to test, the support of peers and family members was key in the decision-making process.
Moreover, social expectations in relation to key life events could encourage HIV testing. Marriage and parenthood were, in many communities, highly valued events that linked an individual to the wider community. Several studies reported HIV testing being understood as a necessary step before marriage.
Similarly, HIV testing was accepted during antenatal care as it helped achieve the social obligation to give birth to a healthy child.
In the light of this, the researchers recommend the expansion of home-based testing and other interventions that focus on couples and households, rather than individuals.
Musheke M et al. A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in sub-Saharan Africa. BMC Public Health 13:220, 2013. (Full text freely available online).