HIV testing preferences in Tanzania: A qualitative exploration of the importance of confidentiality, accessibility, and quality of service

Abstract

Background
HIV counseling and testing (HCT), an effective preventive strategy and an entry point for care, remains under-utilized in Tanzania. Limited uptake of HCT, despite the widespread availability of varied testing options, suggests that existing options may not align well with population preferences for testing.

Methods
Between October and December 2011, we conducted an exploratory study in the Kilimanjaro Region to develop a conceptual framework for understanding which characteristics of HIV testing are associated with preferences for testing. Forty individuals (55% women, 53% never having tested) participated in in-depth interviews and focus groups to identify factors that influence whether and where people test for HIV.

Results
A variety of discrete characteristics of testing venues, test providers, and testing procedures (e.g. distance to testing, counselor experience, type of HIV test, and availability of antiretroviral therapy) mapped conceptually to three domains: confidentiality of testing and test results, quality of HCT, and accessibility and availability of ancillary services. We noted heterogeneous preferences and demonstrate that while some test characteristics overlap and reinforce across multiple domains, others demand clients to make trade-offs between domains.

Conclusion
Testing decisions appear to be influenced by an array of often inter-linked factors across multiple domains, including quality, confidentiality, and accessibility; perceptions of these factors varied greatly across participants and across available testing options. HCT interventions that jointly target barriers spanning the three domains have the potential to increase uptake of HIV testing and deserve further exploration.

Full text

RES E AR C H A R T I C L E Open Access
HIV testing preferences in Tanzania: a qualitative
exploration of the importance of confidentiality,
accessibility, and quality of service
Bernard Njau
1†
, Jan Ostermann
2†
, Derek Brown
3
, Axel Mühlbacher
4
, Elizabeth Reddy
1,2,5
and Nathan Thielman
2,5*
Abstract
Background: HIV counseling and testing (HCT), an effective preventive strategy and an entry point for care,
remains under-utilized in Tanzania. Limited uptake of HCT, despite the widespread availability of varie d testing
options, suggests that existing options may not align well with population preferences for testing.
Methods: Between October and December 2011, we conducted an exploratory study in the Kilimanjaro Region to
develop a conceptual framework for understanding which characteristics of HIV testing are associated with
preferences for testing. Forty individuals (55% women, 53% never having tested) participated in in-depth interviews
and focus groups to identify factors that influence whether and where people test for HIV.
Results: A variety of discrete characteristics of testing venues, test providers, and testing procedures (e.g. distance
to testing, counselor experience, type of HIV test, and availability of antiretroviral therapy) mapped conceptually to
three domains: confidentiality of testing and test results, quality of HCT, and accessibility and availability of ancillary
services. We noted heterogeneous preferences and demonstrate that while some test characteristics overlap and
reinforce across multiple domains, others demand clients to make trade-offs between domains.
Conclusion: Testing decisions appear to be influenced by an arr ay of often inter-linked factors across multiple
domains, including quality, confidentiality, and accessibility; perceptions of these factors varied greatly across
participants and across available testing options. HCT interventions that jointly target barriers spanning the three
domains have the potential to increase uptake of HIV testing and deserve further exploration.
Background
In Tanzania, an estimated 1.5 million people are living
with HIV, 83,000 people are newly infected each year, and
with an estimated 80,000 deaths annually, AIDS continues
to be a leading cause of death among Tanzanians [1,2].
Despite the widespread availability of varied options for
HIV testing, including more than 2,000 HIV counseling
and testing (HCT) sites [3], and a high-profile nationwide
HIV testing campaign, one third of women and half of
men aged 15–49 have never tested for HIV [4]. Further,
only 30% of women and 25% of men tested and received
the results in the past year [1,4].
Alargebodyofliteraturedescribesdiverseapproaches
to HIV testing in sub- Saharan Africa, including Tanzania
[5-13]. Facility-based approaches are most common in
Tanzania and include testing in standalone HIV testing
facilities as well as in clinical settings. The latter includes
client-initiated counseling and testing (CITC) [14] and
provider-initiated counseling and testing (PITC), including
Prevention of Mother to Child HIV transmission (PMTCT)
ser vices [15-17]. Other models , including home-based
counseling and testing, mobile or outreach testing, which
offers testing through mobile vans or organized testing
events, and testing at workplaces or in schools, have also
been occasionally implemented at local levels. Following
considerable investment through the President’s Emer-
gency Plan for AIDS Relief (PEPFAR) and the Global Fund
to Fight AIDS, Tuberculosis and Malaria, HIV testing
became available free-of-charge in Tanzania. Rapid HIV
* Correspondence: n.thielman@duke.edu
†
Equal contributors
2
Duke Global Health Institute, Duke University, Durham, USA
5
Division of Infectious Diseases, Duke University Medical Center, Durham,
USA
Full list of author information is available at the end of the article
© 2014 Njau et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Njau et al. BMC Public Health 2014, 14:838
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tests, now the standard of care, ensure that results are
available to clients immediately after the test.
In Tanzania, voluntary counseling and testing (VCT)
has been the main model through which individuals learn
their HIV status. Acknowledging that client-initiated test-
ing falls short of capturing important patient groups, the
Ministry of Health and Social Welfare in 2007 developed
guidelines for HCT in clinical settings, indicating that
HCT should be recommended by health care providers as
part of the standard of care [15,16]. Despite this recom-
mendation and the widespread availability of diverse HIV
testing options, testing rates remain low [18-20].
Many factors contribute to limited uptake of HIV testing
in Tanzania and elsewhere in sub-Saharan Africa (SSA),
including psychological, cultural, economic, and other fac-
tors such as fear and stigma [21-24]. Some of these factors
may be mitigated over time through community-based
interventions and cultural shifts. Other barriers may be
addressed, or compensated for, by making HIV testing
options more attractive, more convenient, or otherwise
better aligned with population preferences for testing. Dif-
ferent approaches have been developed to address barriers
to testing, such as mobile, school, workplace, or home-
based testing, couples testing, and self-testing [5,6,8-10].
While these approaches were often found to be effective
in getting additional people to test, it is not clear which
characteristics of testing options most influence individ-
uals’ testing decisions. A better understanding of HIV test-
ing preferences may allow for the design of testing options
that better match the preferences of diverse populations.
In preparation for a structured, population-based
assessment of HIV testing preferences, we conducted in-
depth interviews (IDIs) and focus group discussions
(FGDs) in Northern Tanzania to identify characteristics
of HIV testing options associated with individuals’ pref-
erences for HIV testing.
Methods
Overview
IDIs and FGDs were used to identify preference-relevant
characteristics of HIV testing options, and to derive direc-
tional hypotheses with respect to their expected influence
on testing decisions. First, IDIs with diverse community
members were used to inform the development of FGD
guides. FGDs were subsequently conducted with male and
female adults who had previously tested for HIV and with
others who had never tested.
Implementation, analysis, andinterpretationofthisquali-
tative study are consistent with Biomed Central’s Relevance,
Appropr iateness, Transparency, and Soundness (RATS)
guidelines for qualitative research [24]: The study addresses
the highly relevant research question of which characteris-
tics of HIV testing options are associated with individuals’
preferences for testing; IDIs and FGDs with participants
representing diverse experiences and opinions were con-
sidered the most appropriate methods to obtain the neces-
sary information; the study transparently describes the
sampling and analytic methods as well as ethical consider-
ations; and the results of sound analysis and inductive
identification of themes, supported by illustrative quotes,
are presented in the context of the existing literature on
barriers to HIV testing.
Study setting
The study was conducted between October and December
2011 in Moshi, Tanzania. In 2012, the town had a night-
time population of 184,292 [25]. At the time of the study,
18 facilities provided HCT services in Moshi, including
hospitals, health centers, and free-standing VCT facilities.
Intermittently, mobile and outreach testing has also been
available at venues such as schools, markets, or work-
places; a prominent example was a high-profile nationwide
HIV testing campaign which in 2007 and 2008 attracted
more than 3 million testers, including more than 24,000
testers in Moshi [26]. For clients who test HIV positive, 8
HIV care and treatment centers (C TCs) provide access to
antiretroviral therapy; an additional 13 CTCs operate in
the two surrounding districts [27].
Study participants
Purposive sampling [28] was used to recruit 4 male and 4
female IDI participants from diverse settings, including a
bus stop, a market, a home, an office setting, and a guest
house. Subsequently, participants in 4 FGDs, stratified by
gender and HIV testing status (previously tested for HIV
vs. never tested for HIV), were recruited through door-to-
door contact in one of Moshi’s most densely populated
wards. Twelve individuals were invited to each group. In
total, 32 persons participated in FGDs; with 6 to 9 partici-
pants per group. The sampling approach was chosen to
ensure the inclusion of a variety of viewpoints and diverse
experiences among participants.
In-depth interviews and focus group discussions
IDIs and FGD were conducted in Kiswahili, the official
language of Tanzania. Separate interview guides were de-
veloped for IDIs and FGDs. First, semi-structured IDIs,
conducted at the respective enrollment venues and last-
ing approximately 1 hour each, assessed motivators and
barriers to HIV testing , and experiences with and atti-
tudes toward diverse testing options. The results were
used to inform the development of a FGD guide.
Next, FGDs, conducted at a health facility in the vicin-
ity of participants’ homes, sought to identify characteris-
tics of HIV testing options that are associated either
positively or negatively with preferences for testing, and
as such function as either motivators or barriers. Extant
literature and results of IDIs formed the basis for a list
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of characteristics of HIV testing options; all HIV testing
characteristics identified as potentially preference-relevant
were probed and the list was iteratively expanded during
consecutive FGDs. FGD participants were asked to
identify factors that influence whether and where peo ple
test for HIV, and a variety of t est ing options, including
different types of testing facilities (hospital- or health
center-based testing, free- standing VCT facilities) and
venue-based testing options (mobile VCT, home-based
VCT, self -testing) were d iscussed to explore positive
and negative feature s. Each characteristic was discussed
until an understanding was developed of t he mecha-
nisms through which th ey influence testing decisions,
and the direction of the effect could be infe rred. Each
FGD la sted approximately 2.5 hours.
Data management and analys is
IDIs and FGDs were analyzed separately. IDIs were tape-
recorded, transcribed, and translated into English. During
the FGDs, notes were taken by two experienced recorders
and two or more investigators, and expanded immediately
after the discussions. Translated transcripts and text notes
were read independently by multiple investigators, and a
note based approach [28,29] was used to identify cha-
racteristics of HIV testing options associated with testing
preferences and testing decisions. Conceptually related
characteristics were later grouped into domains. Represen-
tative, verbatim quotes from in-depth interviews and focus
groups were selected to illustrate key findings.
Human subjects considerations
The st u d y pro t o co l r ece i ve d eth i c a l c l e a r a nc e fro m the
Institutional Re view Board of Duke University, the
Kilimanjaro Christian Medical University College Research
Ethics Committee, and Tanzania’s National Institute for
Medical Research. Written informed consent was obtained
from all participants. Participants were assigned numbers
to ensure anonymity. Participants were compensated for
their participation (approximately US$ 3.00).
Results
Characteristics of study participants are summarized in
Table 1.
In IDIs and FGDs, a variety of characteristics of HIV
testing options emerged as influencing HIV testing de ci-
sions. Characteristics were grouped into domains, with
some characteristics found to be related to more than
one domain.
Domain 1: confidentiality of testing and test results
Irrespective of gender or HIV testing history, respondents
indicated the importance of confidentiality for the HIV
testing process and disclosure of test results. This was one
of the strongest held views among the four groups, and
there was no dissent as to its importance. Several respon-
dents gave specific examples that highlighted conse-
quences of breaches in confidentiality, including possible
negative reactions by partners, relatives, employers, or
others to a positive HIV test. A female informant who had
never tested (“non-tester”) said, “I am afraid if I am found
to be HIV positive I may be chased away from my job.”
a) Confidentiality concerns associated with venue
Perceptions of confidentiality were associated with char-
acteristics of testing venues, as well as the counselors
providing testing. There was a general consensus that
hospital-based testing afforded greater confidentiality.
“There is a big difference in confidentiality for HIV test
results. In [large hospitals] there is confidentiality of
client’s results. In free-standing HIV sites, you may get
tested and within a few days you may start hearing
people talking about your results.” (Male non-tester, IDI).
Several participants indicated that the large size of a hos-
pital provided a greater degree of anonymity, particularly
in comparisons with an alternative such as home-based
testing. Others mentioned that people go to hospitals for
many reasons, masking hospital-based HIV testing. Partici-
pants voiced concern about lack of privacy in high-volume
testing centers or mobile counseling and testing in tents. A
male FGD participant who had previously tested said, “You
find that a center has so many people that during an inter-
view by the counselor, others outside the room hear all that
you are discussing.” In the context of home-based testing,
there was apprehension that home visits by HIV coun-
selors, identified as such, would be noticed by neighbors; a
female who had never tested was also concerned about
immediate disclosure.
“Most people are afraid to get tested for HIV at home,
because people in most relationships are not faithful.
So, if they test at home they have to disclose their HIV
test results.” (Female non-tester, FGD)
Table 1 Characteristics of study participants (N = 40)
Women (n = 22) Men (n = 18)
In-depth interviews 5 22.7% 3 16.7%
Focus group discussions 17 77.3% 15 83.3%
Mean age in years (range) 40 (18–57) 35 (19–60)
Married (vs. not married) 9 40.9% 8 44.4%
Primary education or less
(vs. secondary education or higher)
13 59.1% 6 33.3%
Previously tested for HIV
(vs. never tested for HIV)
9 40.9% 10 55.6%
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b) Confidentiality concerns associated with counselor
characteristics
Counselor characteristics associated with confidentiality
were primarily age and experience.
“I would prefer a female counselor, older, around
50 years or above, with nice language, who has respect
for her clients. Young counselors are not well
experienced and may be tempted to expose the test
results of their clients.” (Female non-tester, IDI)
Some participants indicated a strong preference against
a counselor th ey know or who resides in t he same
neighborhood.
“When a counselor come s from your neighborhood it is
bad because she could gossip … so I will go far for HIV
testing where I know I will find people who don’t know
me.” (Male tester, FGD)
For others this was not important because a chance
emains that they will meet the counselor again after
their HIV test.
“Icametotesthereat[healthfacility].Ididnot
know th e counselor I found and I did not e ven know
where she live s , but late r she came to rent in my
neighborhood. Therefore, I think there is no reason
to know where a counselor comes from.” (Male
tester, FGD)
Domain 2: quality of the counseling and testing
procedure
Participants related characteristics of the testing venue
and testing providers, and the type of HIV test, to per-
ceptions of the quality of HIV counseling and to the ac-
curacy of HIV tests.
a. Quality of counseling
Respondents underscored the importance of adequate,
unhurried counseling prior to HIV testing.
“It is very important for clients to receive adequate
counseling before being tested for HIV. It is important
for counselors to have enough time for the counseling
sessions. For example, a counselor may want to stay
for 30 minutes, while I would prefer 2 hours, so that I
can be well counseled and then decide to get tested.”
(Male tester, IDI)
Concerns about adequate counseling time were voiced
for high volume testing venues, including hospitals and
mobile testing. Some participants considered facilities
with an exclusive focus on HIV testing a s more special-
ized than other settings, such as a hospital.
“For other centers it is doubtful that they can be as
specialized, because they provide other services.
Free-standing sites provide the best kind of counseling,
because they are only specialized in HIV testing.”
(Male tester, FGD)
Age and experience were the most commonly men-
tioned counselor characteristics associated with testing
preferences. While many participants had no gender pref-
erence, several informants, primarily females, preferred to
be tested by female testers. However, these preferences
were related more to personal comfort than concerns
about quality. Some participants preferred to be tested by
doctors rather than nurses or HIV counselors.
“I would prefer a doctor, because a doctor is more
knowledgeable than a nurse … The doctor should be
40 years or older and experienced in HIV counseling
and testing.” (Female non-tester, FGD)
b. Accuracy of HIV tests at different venues
Participants believed that the accuracy of tests differed be-
tween testing sites. Reasons for such differences included
the availability of more than one type of test, the use of mul-
tiple tests, and the training of those administering the test.
“There are differences in HIV tests in free-st anding
sites compared with hospitals. For example, you may
test at a free-standing site, and receive positive HIV
results. Nevertheless, if we decide to re-test in a
hospital you may get negative HIV results. In addition,
at a hospital you may test urine, sputum, and saliva,
etc.” (Male non-tester, IDI).
Informants generally associated large hospitals with
more accurate HIV tests; private facilities were associ-
ated with less accurat e HIV tests. A male IDI informant
who had ne ver tested, said, “Private HIV counseling and
testing site s […] don’t use accurate HIV tests. I don’t trust
the results from such sites.”
Counselor training was also mentioned as a reason for
differing accuracy between venues. Counselors who test
many people at a large hospital were perceived to pro-
vide more accurate results. By contrast, a female tester
was concerned about mobile testing:
“It is possible that people who conduct the mobile
testing are untrained and may fail to interpret my
HIV results correctly. You may receive incorrect HIV
test results, and this may cause unnecessary anxiety. ”
(Female tester, FGD)
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c. Accuracy of different HIV testing procedures
Significant discussion revolved around the accuracy of
different HIV testing procedures. While several partici-
pants suggested that fear of needles is an important bar-
rier to testing, when asked about their preference for
specific procedures, the primary concern was accuracy.
Participants were roughly evenly split between those
who preferred venipuncture and those who preferred a
finger prick for obtaining the blood sample. Participants
who preferred venip uncture generally considered blood
samples from a large vein in the arm to be more reliable
than a finger prick for HIV testing.
“Blood from a finger prick is to test for Malaria. Blood
to test for HIV comes from the big vein, because it
flows with pressure and I will be sure that my HIV test
results will be accurate.” (Female tester, FGD)
Self-test kits were not considered a feasible option for
wide-spread HIV testing in this setting ; participants
voiced concerns about accuracy, and about the lack of
support from trained counselors to assist with a positive
test result.
“I won’t be sure if the self-test results are accurate. For
example, I won’t be sure on how long the reagents have
stayed in the drug shop/or pharmacy. In such cases,
I may get an incorrect test results. It will be very
difficult.” (Male tester, IDI)
Literacy concerns were also raised.
“Most people, particularly in the rural areas are
illiterate; they can’t read even a newspaper. How can
they be able to read and follow the instructions of how
to use the HIV testing kits?” (Male tester, IDI)
Domain 3: accessibility of testing and other services provided
Additional discussion centered on the importance of dis-
tance to the testing venue, transport cost, testing times,
and waiting times for the accessibility of HIV testing,
and on options for making testing more attractive, by
offering HIV testing in conjunction with other services
or even paying people to test.
a) Accessibility of HIV testing
Many participants did not consider transport costs a
barrier in an urban setting due to the availability of local
testing sites, however, others indicated that they, or
other people, may prefer not to test close to home:
“Personally, I will not go far to test for HIV. But there
are people in the community who travel to other
places to test for HIV.” (Male non-tester, IDI)
Most participants indicated that they are ready to wait
for a substantial amount of time before seeing a
counselor. However, a longer waiting time was also asso-
ciated with an increased risk of compromi sing confiden-
tiality; a female tester was concerned that “someone who
knows you may come”. (Female tester, FGD)
Time conflicts with other activi ties were only men-
tioned in the context of home-based testing.
“[……..] it depend s on my time availability. For
example a health worker may come, while I am
leav ing to go to work , or any other activitie s. I will
not agree to test because of lack of time."
(Male tester, IDI)
Nonetheless, participants indicated that providing HIV
testing services off hours or during weekends could be
beneficial to some, particularly to people who are busy
or employed.
b) Ancillary services
Availability of antiretroviral medications at the testing
site wa s perceived as a motivating factor for HIV test-
ing among some respondents. A male participant pre-
ferred to test in a hospital setting a s the transition
from being a testing client to be coming a patient would
be smoother.
“… you receive your results on the spot and if you have
any problems it is easier to see a doctor or enroll for HIV
treatment or other support.” (Male non-tester, IDI)
Other participants indicated that the availability of
other services would help to reduce stigma and increase
convenience.
Several female discussants mentioned antenatal care as
an entry point for their first testing experience; and both
male and female discussants saw antenatal care a s an
opportunity to get more men to test.
“Pregnant women should be encouraged to ask
their spouses or partners to accompany them to
clinic. It should be conditio nal, that if they are not
accompanied by their spouses or partner, then they
will not receive any serv ices or retain their clinic
attendance cards. They will come in the ne xt
visit with their spouses or partners.” (Female
non-tester, FGD)
c) Payment for testing
Testing is generally provided free of charge in the study
area. Respondents reacted very differently when asked if
they would agree to test for HIV if they are paid. Several
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participants disagreed strongly with payments for test-
ing, as illustrated by a male non-tester.
“No. Because that will look like I am tempted to be tested
for HIV and it is not my own decision or will. It will
appear as if I am being bought.” (Male non-tester, IDI)
Others suggested that payments could be used to get
more people to come for testing.
“My experience is that if it is announced that people
will be paid Tsh 5,000/= (US$3) to test for HIV, and
considering the harsh economic conditions, the space
at [VCT site] will be small.” (Male tester, FGD)
Payment in the form of a transport cost reimbursement
was also considered to have the potential to influence test-
ing decisions, or enable people to mitigate confidentiality
concerns, as indicated by a female discussant who said, “If
my transport costs will be reimbursed, I will travel outside
Moshi to get tested for HIV.” (Female non-tester, FGD)
Concept mapping
Figure 1 summarizes the preference-relevant characteris-
tics of HIV testing options identified in FGDs and IDIs
(in boxes) and visually describes their relationship to the
three underlying domains (in ovals). The domains are
broadly defined as quality of counseling and testing,
confidentiality of testing and test results, and accessibil-
ity and ancillary services. The quality domain includes
characteristics such as the accuracy of the HIV test, the
perceived quality of testing procedures, adequate time for
counseling, and the e xperie nce of coun selors. The con-
fidentiality domain includes characteristics perceived to
be assoc iated with a potenti al disclosure of HIV test re -
sults (e.g. by a younger counselor, or in a mobile setting)
and characteristics associated with the inadvertent dis-
closure of testing per se. Examples for the latter include
testing close to home, familiarity with the counselor,
te sting at a facility that onl y offers HIV test ing, and long
waiting times or large numbers of client s that increase
the risk of familiar encounter s. The accessibility domain
describes the time and moneta ry cost of accessing test-
ing, and opportunities for c ombining HIV testing with
other services.
Most characteristics of HIV testing options related to
multiple domains. For example, counseling by a counselor
who is known to a participant may be associated with per-
ceptions of a higher quality of counseling or with concern
about confidentiality. Similarly, the type of facility is asso-
ciated with the concepts of quality (e.g. perceived more
accurate test results in hospitals or better counseling in
dedicated HIV testing facilities), accessibility (e.g. by com-
bining HIV testing with other screening or treatment
services), and confidentiality (e.g. by having other reasons
to be seen at a hospital). Associations between characteris-
tics and domains are indicated by the placement and shad-
ing of each characteristic. The multi-faceted relationship
of testing characteristics with the three domains is indi-
cated by each box’s shading with multiple colors.
Figure 1 Concept map of HIV testing characteristics.
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Discussion
In-depth interviews with key informants and focus group
discussions elucidated a variety of preference-relevant char-
acteristics of HIV testing options, which map conceptually
to three domains: confidentiality, quality, and accessibility.
Not surprisingly, as others have clearly documented
[21-23,30], concerns about confidentiality were preeminent
and likely to affect HCT utilization. Our data highlight a
level of unease about potential inadvertent disclosure of
HIV status or HIV testing in association with specific test-
ing venues, including free-standing and mobile VCT sites
and testing at home. Similar apprehension was expressed
about HIV testing conducted by young counselors, who
were perceived to be possibly less discreet than older ones.
Because the desire for confidentiality is linked to stigma,
our findings highlight the importan ce of addressing
both confide ntiality and stigma in the design of new er
approaches to HCT .
Concerns about accuracy were related to specific
venues, the training of test providers, and the type of
test. Some respondents feared that private or free-
standing testing sites were prone to providing false posi-
tive results , whereas counselors with more experience,
especially those working in large hospitals , are likely to
deliver more ac curate results. Variati on in perceived ac-
curacy was also related to differences in test s and test-
ing proced ures across venues . Home testing did not
appear to be a popular option, even among those who
had previously tes ted, in part due to confidentiality con-
cerns , but also be c ause the qu ality of home testing was
potentially suspe c t. It has b een p re viously documented
that perceived unreliability oftestresultsanddistrustof
HIV tes ting tech nologies can discourage uptake of HIV
testing [22,31,32].
The findings highlight the conceptual overlap between
testing venue, counselor, and test characteristics and sug-
gest that individuals make important trade-offs in consid-
ering testing options. Some prefer to test at venues that
see more clients, where they perceive the accuracy of the
test to be better. Others, concerned more about confiden-
tiality, may be willing to sacrifice perceived more accurate
testing at a high-volume testing center for a perceived
lower risk of being seen testing at testing sites with fewer
clients The heterogeneity of preferences and the complex
links between the domains of quality, confidentiality, and
accessibility should be accounted for in the design or re-
design of testing options.
To address both confidentiality and quality concerns,
the integration of testing services into a hospital or
health center setting may be preferable to isolated test-
ing services offered at free-standing facilities. As attend-
ance at free-standing HIV testing sites appears to be
declining [33], plausibly because clients prefer to access
HCT services within health facilitie s, HCT policy makers
should examine ways to re-define the roles of free-
standing VCT sites in this context.
The focus group discussions demonstrated heteroge-
neous preferences with respect to the accessibility of
testing. For many participants, distance wa s not a signifi-
cant barrier due to the local availability of a variety of
testing options. For others, traveling seemed advanta-
geous, as testing done farther from home is more likely
to be confidential. Disparate views were expressed re-
garding direct payments as means of increasing accessi-
bility of testing. We note that in the context of selected
studies that addressed a slightly different question, high
value conditional cash transfe rs, given in exchange for
testing negative for sexually transmitted infections, were
associated with reduced infection [34-36].
With the introduction of newer approaches of HCT
delivery such as the use of community based lay coun-
selors [37], couples counseling and testing [7,8,38],
provider-initiated [39,40], home base d [5,11,12], and mo-
bile HCT [13,23,41], it is important for planners of HIV
testing interventions to re cognize that many barriers are
inextricably linked. Some are overlapping and reinfor-
cing (e.g. concerns about both quality and confidentiality
with home testing), and others demand that patients
make trade-offs as they choose to test (e.g. paying for
travel to reduce risk of disclosure within one’s commu-
nity). Novel approaches to HCT delivery must weigh the
benefits of addressing heterogeneous preferences against
the costs and complexities of addressing the multi-
faceted and interlinked barrie rs.
Limitations
Our st udy is subje ct to important limitations. IDIs and
FGDs afforded an opportunitytoidentifyavarietyof
characteristics of HIV testing options associated with
preferences, and to begin to understand which features
are most important. Howev er, our study sug gests sig-
nificant preference heterogeneity among participants ,
which precluded the development of a consensus re-
garding the relative importance of specific characteris -
tic to participants, or to differentiate the preferences of
individual sub-groups. The existence of heterogeneous
preferences has been confirmed by a quantitative follow-
up study in the area [42].
Second, it is not clear how participants’ stated prefer-
ences relate to actual testing decisions. The preferences
and characteristics of individuals are likely to interact with
characteristics of testing options (e.g. venue, method for
obtaining the sample for the HIV test) to influence actual
testing decisions. Further, due to the focus of FGDs and
IDIs on characteristics of testing options, several import-
ant elements of the decision process could not be explored
in detail, including differences between first-time and re-
peat testing, external motivators, such as social support
Njau et al. BMC Public Health 2014, 14:838 Page 7 of 9
http://www.biomedcentral.com/1471-2458/14/838

for testing, and internal barriers to testing, such as fears of
knowing the result.
Finally, an inherent weakness of this qualitative study
is that the findings may not be representative of the
population in the study area and may not be applicable
to other settings. Because study participants were re-
cruited from an urban setting with comparatively wide-
spread access to a variety of HCT services, our findings
may not be as relevant in rural areas.
Conclusion
This study identified several important attributes of HIV
testing options that are associated with HIV testing prefer-
ences. Testing decisions appear to be influenced by an
array of often inter-linked factors across multiple domains,
including quality, confidentiality, and accessibility; and
perceptions of these factors varied greatly across partici-
pants and with available testing options. HCT interven-
tions that jointly target barriers across these domains have
the potential to increase uptake of HIV testing and de-
serve further exploration.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
All authors (BN, JO, DB, AM, ER, and NT) planned the study activities and
developed the study protocols. BN led the qualitative components of the
study, oversaw their implementation, and conducted the FGDs. BN, JO, and
NT developed the FGD guides. JO, DB, ER, and NT attended FGDs. BN, JO,
and NT analyzed the data and prepared a draft manuscript. All authors
contributed to the final version of the manuscript. All authors read and
approved the final manuscript.
Acknowledgements
This publication was made possible by Grant Number R21 MH096631 from
the National Institute of Mental Health, and supported by the Duke
University Center for AIDS Research (CFAR), an NIH funded program
(5P30 AI064518). The contents of this publicati on are solely the responsibility
of the authors and do not necessarily represent the official views of the
National Institute of Mental Health or the National Institutes of Health. We
gratefully thank all study participants and acknowledge Elizabeth Mbuya and
Beatrice Mandao for study implementation and data collection; Bernard
Agala and Tara Mtuy for assistance with qualitative research; and the
Kilimanjaro Clinical Research Institute for administrative support.
Author details
1
Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania.
2
Duke Global Health Institute, Duke University, Durham, USA.
3
Brown School,
Washington University in St. Louis, St. Louis, USA.
4
Hochschule
Neubrandenburg, Stiftungsinstitut Gesundheitsökonomie und
Medizinmanagement (IGM), Neubrandenburg, Germany.
5
Division of
Infectious Diseases, Duke University Medical Center, Durham, USA.
Received: 11 February 2014 Accepted: 4 August 2014
Published: 12 August 2014
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doi:10.1186/1471-2458-14-838
Cite this article as: Njau et al.: HIV testing preferences in Tanzania: a
qualitative exploration of the importance of confidentiality, accessibility,
and quality of service. BMC Public Health 2014 14:838.
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