Introduction

Since HIV tests became available in the mid-1980s, concerns about human rights have led to heated discussions among those promoting wider testing and those who fear the social consequences of positive diagnoses. In the early years of the epidemic, a degree of “exceptionalism” characterized policies around HIV, whereby public health measures that were considered normal for other diseases, including routine testing, were deemed unacceptable in the case of HIV, because of the potential for stigma and discrimination [1]. Proponents of wider testing maintained that traditional modes of voluntary counseling and testing (VCT) could not sufficiently expand access to treatment and prevention [2], but many human rights advocates were reluctant to endorse the routinization of testing or its expansion at health facilities. They argued that the potential benefits did not outweigh the risks, that only client-initiated VCT was acceptable, and that careful scrutiny of consent procedures and practices around confidentiality was necessary [3]–[6]. Despite the wider availability of treatment, there are continuing concerns about expanding testing if consent, confidentiality, and proper care cannot be guaranteed [1],[3].

Until recently, the evidence to inform debates around HIV testing was patchy, in part because of the lack of unified criteria to measure outcomes, particularly in sub-Saharan Africa. In addition, studies that examined the shift from client- to provider-initiated testing tended to focus on acceptance rates rather than on actual testing experience [7]. There have not been systematic examinations of differences in outcomes for VCT compared to provider-initiated testing and counseling (PITC).

In the past few years, growing interest in monitoring HIV testing has led to the formulation of guidelines to ensure that practices around informed consent, confidentiality, and care respect the rights of clients. In 2007, the World Health Organization published a guidance document on PITC, shortly after the US Centers for Disease Control and Prevention had developed their own guidelines, and in 2009, European countries formulated guidelines to define minimum standards of what should be provided everywhere [8]–[10] (see also the more recent summaries [11],[12]). Despite some variations, these international guidelines represent a useful basis to define a set of outcomes that are measurable across settings.

The MATCH (Multi-Country African Testing and Counseling for HIV) study was designed to conduct systematic comparisons across countries of different ways of providing HIV testing (referred to here as modes of testing). Its overall goals are to investigate the uptake of testing, to analyze differences in the experience of testing across countries and modes of testing, and to assess the implications of these results for policies designed to increase knowledge of HIV status and referral to care. The project formulated a number of specific aims regarding variations in services around testing, in motivations to test, and in the experience of testing and its consequences, as reported by clients and by providers. Different sorts of data were collected, ranging from large surveys of clients using precoded responses (used in this analysis) to qualitative data transcribed from semi-structured interviews with key informants (not used in this analysis). Analyses of MATCH data focus on particular subsets of the data, for example, those pertaining to attitudes towards testing, the extent of stigma, or the frequency of disclosure of HIV status. In this analysis, we focus on services related to testing and examine the extent to which consent, confidentiality, and referral to care vary across modes of testing, namely VCT and PITC.

MATCH was conducted in four countries—Burkina Faso, Kenya, Malawi, and Uganda—that exemplify different approaches to the provision of services. In all four countries, multiple government- and donor-supported initiatives have been implemented, and, increasingly, testing is conducted at health facilities. But testing practices reflect the countries' different histories with HIV testing and foreign aid, and there are differences in the pace of increase (somewhat slower in Burkina Faso), in the scale of the resources invested (larger in Kenya and Uganda), in the role of VCT (which still represents an important mode of provision in Burkina Faso and Uganda), and in the relative roles of governments and nongovernment organizations. All four countries face similar challenges with the expansion of testing: insufficient resources, infrastructure, and adequately trained staff; limited public awareness about the risks of HIV; and difficulties with referral and follow-up. But while fears of coercion and breaches of confidentiality are frequently invoked in the literature, it is unclear whether these differ depending on how testing is provided, and how clients feel regarding their experiences with different modes of testing.

This paper analyzes respondents' reports regarding consent, confidentiality, and referral, to assess whether these outcomes differ systematically by mode of testing. Specifically, we assess whether eight outcome measures related to the completeness and quality of services—including the adequacy of pre- and post-test counseling, clients' consent to test, confidentiality, satisfactory interactions with providers, and referral for those HIV positive—differ between provider-initiated and client-initiated modes of testing. The null hypothesis, that there are no significant differences, would suggest that inadequate outcomes are not more likely when testing is scaled up at health facilities.

Methods

Study Design and Sample

The core component of the MATCH study is a client survey, conducted in 2008–2009 at health facilities. It was designed to represent users of health facilities in the capital city and one province in each country, and to include individuals who had tested and others who had not tested for HIV. In each country, the research team, which comprised individuals knowledgeable about HIV testing, drew up a list of health facilities or services within large facilities that provided HIV testing, and facilities or services known not to provide HIV testing. The list of facilities for testers included the major providers of testing services and different types of facilities, namely, stand-alone facilities for VCT and integrated facilities where testing was provided along with prenatal care, tuberculosis treatment, or general medical care. Non-testers were recruited at medical facilities or services where HIV testing was not provided. Testing status was ascertained for all respondents. Other components of the MATCH study, not incorporated into this analysis, include smaller surveys of clients tested at home or during campaigns, interviews with providers, and semi-structured interviews with selected clients and providers.

About 20 facilities or services within larger facilities were selected for inclusion in each country. Adult clients (aged 18 y and over) who were present at the selected facilities on the appointed days were invited to participate in the study. All respondents who agreed to discuss their experience with testing or not testing for HIV were included. Response rates are estimated at 80% in Burkina Faso and 90% in Malawi and Uganda; the figure for Kenya is considerably lower, at about one-half, reflecting the difficult political situation prevailing in 2008, which translated into poor security, reluctance to participate, and cancelling or aborting of interviews.

The instrument used in the client survey included closed- and open-ended questions about socio-demographic information; attitudes towards HIV testing and counseling; testing status; for those previously tested, a checklist on services received during pre- and post-test meetings and follow-up care; and interactions with providers and experiences before, during, and after testing, including disclosure and stigma. The interview was piloted in the four countries and revised in light of field experience to ensure that the questions were understood and the sequence of questions was adequate. Interviews lasted approximately 30 min.

A total of 3,659 respondents were interviewed at the selected facilities in the four countries. Because we were interested in recent testing experience across different modes of testing, this analysis focuses on respondents who reported testing at different sorts of facilities in the 2 y preceding the survey. We excluded non-testers (1,088); testers who reported testing before 2007 or who were missing information on test date or testing status (385); those missing data on place of test or whose place of test could not be categorized, for example, if they tested abroad (34); and those missing information on covariates (36). Thus, the analysis includes 2,116 respondents tested at different types of facilities in 2007 or later. Each outcome was analyzed using a complete case method. Denominators are not the same for all outcome measures, for example, respondents who did not meet with a counselor before their test were not eligible to answer questions about the quality of pre-test counseling. The final sample values are found in Table 1. The analysis is stratified by country, because differences in policy environments and in the implementation of HIV testing made it plausible that there would be different associations in the four countries between test modes and the outcome measures in which we were interested.

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Table 1. Percent respondents reporting on outcome measures of HIV testing, by country and mode of testing.

https://doi.org/10.1371/journal.pmed.1001329.t001

This analysis is designed to assess the extent to which respondents' experiences with testing are consistent with prevalent standards for the quality and completeness of the services to be provided along with HIV testing. We draw on data collected in response to questions and checklists regarding respondents' testing experience, including the information, advice, and referral that were provided during pre- and post-test counseling, interaction with providers, and the extent to which clients' rights were protected by practices regarding consent and confidentiality. We assess whether there are differences in these responses for clients tested at different types of testing facilities, adjusting for respondents' socioeconomic characteristics and for the clustering of responses in interview facilities.

Results

The distribution of respondents by testing mode differs across countries. More respondents tested at stand-alone VCT sites than at integrated sites in Burkina Faso (55% [293/537] and 26% [138/537], respectively) and Uganda (47% [315/664] and 38% [255/664]), while more tested at integrated sites than at stand-alone VCT sites in Malawi (65% [348/533] and 8% [43/533], respectively) and Kenya (70% [268/382] and 9% [34/382]). PMTCT testers ranged from 14% (94/664) in Uganda to 27% (142/533) in Malawi. (Detailed frequencies of respondents' age, sex, educational attainment, and wealth score quartiles, by country and mode of testing, are presented in Table S1.)

Table 1 presents the frequencies of respondents' reports on the eight outcome measures across all countries and for each country.

Across all countries, respondents in integrated testing were less likely to meet with a counselor before their HIV test (83% compared with 95% of VCT testers; p<0.001), but those who did meet with a counselor were more likely to have completed consent procedures (89% compared with 83% among VCT testers; p<0.001) and pre-test counseling (78% compared with 73% among VCT testers; p = 0.015). Both integrated and PMTCT testers were more likely to receive complete post-test counseling than were VCT testers (59% among both PMTCT and integrated testers compared with 36% among VCT testers; p<0.001). Differences among the three groups in proportion referred to care, proportion satisfied with their post-test counseling, and proportion believing that confidentiality had been ensured were not significant.

Examining the unadjusted associations between testing mode and outcome measures by country reveals some notable differences, as shown in Table 1. In Burkina Faso, integrated testers were significantly less likely to meet with a counselor before their test (67% compared with 96% among VCT testers; p<0.001), to have a complete pre-test index (46% compared with 62% among VCT testers; p<0.001), and to be satisfied with post-test counseling (62% compared with 77% of VCT testers and 77% of PMTCT testers). In Uganda, integrated testers were less likely to meet with a counselor (73% compared with 94% among VCT testers; p<0.001), to have complete pre-test counseling (67% compared with 81% among VCT testers and 77% among PMTCT testers; p = 0.003), to have complete post-test counseling (46% compared with 52% among VCT testers and 67% among PMTCT testers; p = 0.003), and to be satisfied with post-test counseling (65% compared with 80% among VCT testers and 69% among PMTCT testers; p<0.001). In Malawi, VCT testers were less likely to receive full post-test counseling than PMTCT or integrated testers (54% of VCT testers compared with 71% of integrated testers and 75% of PMTCT testers; p = 0.023). In Kenya there were no significant differences across testing modes.

Table 2 presents the effects of mode of testing on the eight outcome measures, after adjustment for respondent age, sex, educational attainment, and wealth. In Burkina Faso, satisfaction with post-test counseling remained significantly higher among VCT testers than among integrated testers; the adjusted prevalence ratio (APR) comparing VCT testers to integrated testers was 1.28 (95% CI: 1.10–1.48). In Uganda, respondents testing in stand-alone VCT sites were significantly more likely to meet with a counselor (APR: 1.25; 95% CI: 1.04–1.51), to have completed confidentiality procedures (APR: 1.13; 95% CI: 1.04–1.23), and to be satisfied with their post-test counseling experience (APR: 1.23; 95% CI: 1.10–1.37), while HIV-positive PMTCT testers were significantly less likely to receive referrals for additional care (APR: 0.71, 95% CI: 0.57–0.89). In Malawi, respondents testing in stand-alone VCT sites were significantly more likely to meet with a counselor before testing (APR: 1.11; 95% CI: 1.05–1.18).

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Table 2. Prevalence ratios for outcome measures, by country and mode of testing.

https://doi.org/10.1371/journal.pmed.1001329.t002

Analyses of the pooled data across countries show a higher likelihood of a pre-test meeting for VCT (APR: 1.22; 95% CI: 1.07–1.38) compared to integrated testing, and higher satisfaction for VCT compared to integrated testing (APR: 1.15; 95% CI: 1.06–1.25). Other differences were not statistically significant.

Discussion

First, a major result of this analysis is that across all countries and modes of testing, high percentages of clients reported having received the services around testing that are considered important in most guidelines. As shown in Table 1, across the four countries, 89% reported having a pre-test meeting, and more than 75% reported a complete pre-test index. Consent, confidentiality, and overall satisfaction indices were high, at 86%, 79%, and 81%, respectively. Provision of post-test services was generally lower: though 99% received their results, just over half reported a complete post-test index, and 71% of HIV-positive respondents reported a complete referral index. This suggests that there is still a good deal of room for improvement to provide advice and referral after HIV testing, but that services around testing do not appear to be associated with major breaches of autonomy or privacy. When we compared reports by HIV-positive and HIV-negative respondents, we found them to be similar, and where they differed, HIV-positive respondents reported more favorably on the services received, which does not support the notion that HIV-positive individuals receive worse services due to stigma.

A second major result of this analysis is that there were some significant associations between outcome measures and modes of testing, but differences across modes of testing were not consistent with the notion that one mode of testing performs better than the others. As shown in Tables 1 and 2, unadjusted analyses indicate somewhat more favorable reports at integrated testing sites on a few outcome measures, while analyses adjusting for covariates and clustering of facilities show slightly higher likelihood of better outcomes for VCT. In general, the results do not support the notion that testing at integrated health facilities functions less adequately than at stand-alone VCT sites.

Taken together, these results suggest that the rights of clients, particularly regarding informed consent and confidentiality, can be protected even as testing is scaled up at health facilities. Some studies have suggested that consent and confidentiality may be jeopardized by inadequate facilities and procedures, poor counseling, or the power differential between providers and patients [20]–[27], while other studies have documented high acceptability and improved referral, with no reduction in the utilization of health services when testing is routinized [7],[28]–[30]. The results of this analysis are consistent with studies showing that routine testing is compatible with ethical practices [31],[32], and this should provide some reassurance about the possibility of scaling up HIV testing through PITC without compromising individual protection.

The association of VCT with more positive outcome measures than integrated or PMTCT testing in Uganda—specifically pre- and post-test counseling, receiving results, and satisfaction—can be attributed to the role of nongovernment organizations, which mobilized early on, when VCT was the only mode of provision, to encourage testing, increase awareness, and fight stigma and discrimination. The less favorable outcomes for pre- and post-test counseling in Burkina Faso may be attributable to the more recent initiation of PITC in the country, which had, for a long time, relied on VCT provided via freestanding facilities and national campaigns. PITC facilities are comparatively less resourced in Burkina Faso, and the guidelines in place at the time of the survey did not recommend all of the post-test items that we included in our indices. Instead, the guidelines in Burkina Faso referred to explaining the meaning of results, providing advice on prevention, and answering questions. When measured against more demanding standards, testing services fell short. These results underscore the need to clarify and harmonize guidelines on testing and counseling and to support their implementation.

The data were collected in 2008–2009, at an important time for the scale-up of HIV testing programs. In the countries where the study was conducted, as well as globally, 2006–2007 was a turning point for the increased availability of treatment, the formulation of guidelines, and the implementation of programs to increase knowledge of HIV status. The results reflect the scale-up of these efforts and are likely indicative of subsequent trends.

The generally favorable outcomes that are documented in this study suggest that it is possible to expand client- and provider-initiated testing while protecting patients' rights. This should not be surprising. The standards defined by guidelines on testing, such as informing clients, obtaining consent, and providing information, are not especially exacting, and can be achieved in most settings. Other studies, such as in the United States [33],[34] and in Egypt [35], have reported similarly high levels of service provision ad satisfaction.

It is possible that the high values we found in reported measures of satisfaction result in part from a contrast with clients' general experience with other health services, which tends to be suboptimal, so that, by comparison, the quality HIV testing services appears to be satisfactory. It is also possible that because respondents were interviewed at health facilities, they may have felt that they should not appear ungrateful for the services they receive, and hence may have given more favorable answers. In order to assess the extent of such social desirability bias, we conducted a sensitivity analysis comparing outcomes among respondents who tested at facilities where interviews were conducted and those who reported testing at facilities not included in the MATCH project. We found that outcomes among respondents tested at MATCH facilities tend to be similar to, or less positive than, those who did not test at MATCH facilities, suggesting that the facility environment did not substantially influence respondents' reports on the care they received.

Other studies in Kenya and Malawi have found that counseling may be neglected when testing is scaled up, and that clients may perceive testing as compulsory [36],[37]. Qualitative data such as were used in these studies are important complements to surveys. They provide insights into potential gaps in the functioning of services, highlighting research questions regarding counseling and consent for further investigation and suggesting areas for improvement. Analyses are underway on the texts transcribed from responses to open-ended questions in the MATCH survey, and from the semi-structured interviews carried out in parallel with the survey. The texts provide a complementary way to assess clients' views, and the analyses should yield more detailed insights into the reasons for clients' positive or negative evaluations of their testing experiences.

There are limitations to this study, including the fact that the outcome measures may not account for important social, cultural, and health service variations. Our measures of referral and medication use do not include specific details, and hence provide only a rough measure of referral. In addition, our analysis distinguishes modes of testing as discussed in the literature, and compares VCT and PITC (including integrated and PMTCT testing), but the reality of services on the ground is complex, and the boundaries among types of testing facilities are not always strict. It is also possible that the lack of significant associations between testing mode and outcomes at the level of individual countries reflects the smaller numbers of respondents in some of the categories of testing, and that larger samples may have been able to detect more associations.

A further limitation comes from using a sample of convenience, based on systematic rather than random selection, and hence not necessarily representative. This strategy was deemed to be appropriate, since the goal was to compare testing experiences across modes of testing. MATCH respondents are more urban, educated, and wealthy than respondents to national surveys—except in Malawi, where they are similar [38]–[41]. This is not surprising, since users of health facilities tend to have higher socioeconomic status than the general population. Thus, there are reasons to believe that these results are not gross overestimates and that they reflect the reality of testing in the selected areas.

A strength of this study is that it used the same outcome measures and methodology across sites. Hence, results can be compared across countries to address policy questions about modes of testing. While there are considerable differences, both within and among countries, in the structural factors that define health services and accessibility and the meanings attached to testing, the motivations behind it, and its consequences, there is a degree of consistency in the results that likely reflects the state of services around testing in these different settings.

Supporting Information