HIV testing experiences and their implications for patient engagement with HIV care and treatment on the eve of ‘test and treat’: findings from a multicountry qualitative study

Abstract

ObjectiveIn view of expanding ‘test and treat’ initiatives, we sought to elicit how the experience of HIV testing influenced subsequent engagement in HIV care among people diagnosed with HIV.MethodsAs part of a multisite qualitative study, we conducted in-depth interviews in Uganda, South Africa, Tanzania, Kenya, Malawi and Zimbabwe with 5–10 health workers and 28–59 people living with HIV, per country. Topic guides covered patient and provider experiences of HIV testing and treatment services. Themes were derived through deductive and inductive coding.ResultsVarious practices and techniques were employed by health workers to increase HIV testing uptake in line with national policies, some of which affected patients’ subsequent engagement with HIV services. Provider-initiated testing was generally appreciated, but rarely considered voluntary, with instances of coercion and testing without consent, which could lead to disengagement from care.Conflicting rationalities for HIV testing between health workers and their clients caused tensions that undermined engagement in HIV care among people living with HIV. Although many health workers helped clients to accept their diagnosis and engage in care, some delivered static, morally charged messages regarding sexual behaviours and expectations of clinic use which discouraged future care seeking. Repeat testing was commonly reported, reflecting patients’ doubts over the accuracy of prior results and beliefs that antiretroviral therapy may cure HIV. Repeat testing provided an opportunity to develop familiarity with clinical procedures, address concerns about HIV services and build trust with health workers.ConclusionThe principles of consent and confidentiality that should underlie HIV testing and counselling practices may be modified or omitted by health workers to achieve perceived public health benefits and policy expectations. While such actions can increase HIV testing rates, they may also jeopardise efforts to connect people diagnosed with HIV to long-term care, and undermine the potential of test and treat interventions.

Trends in knowledge of HIV status and efficiency of HIV testing services in Sub-Saharan Africa (2000-2020): a modelling study of survey and HIV testing program data

“…14,[37][38][39][40][41] Retesting can be motivated by multiple factors, one of them being the ability to confirm the accuracy of the initial test result. [41][42][43] Another data. Given the cross-sectional nature of these metrics, they could be more sensitive to the elicited model's prior distributions in early years.…”

Methods, outcomes, and costs of a 2.5 year comprehensive facility-and community-based HIV testing intervention in Bukoba Municipal Council, Tanzania, 2014-2017

“…Supporting prior reports that many PLHIV retest for HIV after diagnosis, BCPE staff used a standard form to identify 1,407 testers who had been previously diagnosed, of whom 819 were currently in HIV care [72, 73]. Thus, routine assessment of prior diagnostic and HIV-care status of all clients who test HIV-positive is critical, and may be particularly important as countries approach diagnostic coverage among PLHIV.…”

Epidemiological profile of individuals diagnosed with HIV: results from the preliminary phase of case-based surveillance in Kenya

“…We did not identify retesting to be specifically related to pregnancy, as less than 11% of women who retested were pregnant. Other studies show that repeat testing for those already diagnosed with HIV has been identified as an issue as some patients question the accuracy of test results (Wringe et al, 2017), or simply wish additional verification. It is important to understand why retesting is occurring, as approximately 8% of cases retesting had already started care at the first facility before being retested at a different facility, which can occur if a patient transfers to another facility without disclosing it to either facility.…”