HIV testing and counselling – listening to the providers

Rewards and challenges of providing HIV testing and counselling services: health worker perspectives from Burkina Faso, Kenya and Uganda.

Bott S, Neuman M, Helleringer S, Desclaux A, Asmar KE, Obermeyer CM2; the MATCH (Multi-country African Testing and Counselling for HIV) Study Group. Health Policy Plan. 2014 Sep 17. pii: czu100. [Epub ahead of print]

The rapid scale-up of human immunodeficiency virus (HIV) testing, counselling and treatment throughout sub-Saharan Africa has raised questions about how to protect patients' rights to consent, confidentiality, counselling and care in resource-constrained settings. The Multi-country African Testing and Counselling for HIV (MATCH) study investigated client and provider experiences with different modes of testing in sub-Saharan Africa. One component of that study was a survey of 275 HIV service providers in Burkina Faso, Kenya and Uganda that gathered quantifiable indicators and qualitative descriptions using a standardized instrument. This article presents provider perspectives on the challenges of obtaining consent, protecting confidentiality, providing counselling and helping clients manage disclosure. It also explores health workers' fear of infection within the workplace and their reports on discrimination against HIV clients within health facilities. HIV care providers in Burkina Faso, Kenya and Uganda experienced substantial rewards from their work, including satisfaction from saving lives and gaining professional skills. They also faced serious resource constraints, including staff shortages, high workloads, lack of supplies and inadequate infrastructure, and they expressed concerns about accidental exposure. Health workers described heavy emotional demands from observing clients suffer emotional, social and health consequences of being diagnosed with HIV, and also from difficult ethical dilemmas related to clients who do not disclose their HIV status to those around them, including partners. These findings suggest that providers of HIV testing and counselling need more resources and support, including better protections against HIV exposure in the workplace. The findings also suggest that health facilities could improve care by increasing attention to consent, privacy and confidentiality and that health policy makers and ethicists need to address some unresolved ethical dilemmas related to confidentiality and non-disclosure, and translate those discussions into better guidance for health workers.

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Editor’s notes: In this paper the authors investigate the experience of health workers providing HIV counselling and testing services in Burkina Faso, Kenya and Uganda. This is an under-researched topic. The respondents in the study appear to have been candid in the articulation of the challenges they face in their work. Instances of breaking the confidentiality of a person to share results with a family member or a church leader were reported. Sometimes this was to protect a partner from infection or ensure the person who had been found to be HIV-positive might access care.  Pressure from husbands or other relatives to disclose results was also reported. Many health care staff were concerned about the danger to a relationship and, most notably, to a woman’s safety that an HIV-positive result may pose. In addition, sometimes confidentiality was broken unintentionally because, for example, of the lack of a private place to share results. The majority of health workers worried about the risk of infection in their day to day work. Yet, the authors also note that in all three countries HIV care providers experience substantial rewards from their work, through saving lives and enhancing professional skills. This very welcome paper highlights the importance of documenting and monitoring HIV testing and counselling services. There is a need to support improvements in services for users and providers.

Burkina Faso, Kenya, Uganda
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