Lay construction of risk of infection & health.
Low self-perception of risk of infection.
Perception of being at less risk of infection and carrying on with life as normal sometimes based on HIV status of sexual partner.
[36, 38, 43–45, 49, 50, 56, 60, 67]
The lack of a sexual partner or abstinence from sex creates perception of being at less risk of infection.
Ill-health &/or death of child/sexual partner.
Experience of sexually transmitted infection, physical deterioration of one’s health or poor health/death of sexual partner/child creates a sense of susceptibility to HIV infection.
[30–33, 37, 39, 40, 42, 43, 48, 49],[55, 56, 59, 60, 65, 67–69]
Social contact with person with HIV.
Personal contact/knowing someone with HIV or who had died of AIDS raise concern about its existence & susceptibility thus creating a sense of vulnerability. In settings with low prevalence creating a sense of vulnerability. In settings with low prevalence HIV raises doubts about its existence, and creates social distance from HIV.
[28, 40, 49]
Risky sexual lifestyle.
Experience of multiple sexual partners, including past sexual life or perceived partner infidelity either creates a sense of susceptibility or creates assumption of already being infected.
[32, 34, 36, 39, 40, 42, 44, 48],[59, 60, 69]
Mental burden of living with HIV.
HIV+ status as imminent death & psychological burden.
In the absence of a cure, despite the availability of ART, HIV positive status perceived as hastening death. Thus, imminent death is avoided by shunning HIV testing.
[29, 33, 34, 37, 38, 40, 42, 44],[47, 48, 53, 55, 57, 60, 65, 68],
| || |
Perceived incapacity to psychologically cope with a positive HIV result & associated lack of will to live with HIV.
[32, 34, 36, 40, 43, 45, 46, 48],[53, 54, 56, 61, 69]
Social support & exclusion.
Family & peer network influence & support.
Social influence and green light from family and friends influence decision making (not) to test.
[36–38, 40, 42, 47, 56–58, 67]
| || |
The fears of losing social/economic (support) networks, including sexual partners discourage HIV testing.
[38–40, 42, 64, 67]
(Mis-) trust in marital relationships.
In marital relationships with perceived mutual trust & fidelity, HIV testing seen as unnecessary. Where there is mistrust, testing is done to allay concerns of infidelity.
[33–35, 44, 45, 50–52, 54, 65]
Blame & partner reaction.
Fear of partner reaction, blame and straining relationships, which sometimes can lead to abandonment, divorce or even violence. Those who decide to test, especially without partner consent fear being held responsible for infidelity. Testing is therefore seen as a spoiler of harmony & trust in relationships.
[31, 35, 37, 43, 47, 57, 68]
Fear of anticipated stigma & discrimination.
Fear of isolation, rejection & blame (for immoral behaviour) discouraging uptake of HIV testing.
[28–31, 34, 36, 37, 39, 40, 45, 46],[48, 49, 51–56, 60, 61, 63, 65, 66],[68, 69]
| || |
Being on ART also creates stigma-“responsible for spreading” HIV
Gender inequality & influence.
Gendered power relationships.
Female lack of negotiating power in marital relationship, including their lack of control over their health affects uptake of HIV testing. On the other hand, male domination of decision making, and their control over household resources enables them easily access testing.
[30–32, 35, 42, 43, 47, 51, 52, 55],[57, 59, 68]
Maintaining masculine identity.
Men also exhibit reluctance to test to preserve their masculine identity as strong and resilient. Others test in order to start treatment in order to maintain their status as breadwinners
[30, 36, 37, 67, 68]
Reproductive health aspirations.
Procreation & marital aspirations.
Larger social & reproductive health aspirations motivation for HIV testing. For women, testing invokes maternal duty the unborn child.
[29, 34, 40–44, 46, 47, 52, 54, 58],
| || |
Desire to marry also prioritized; testing and being found HIV positive perceived as reducing chances of finding marital partner unless potential partner is also infected; others fear that sexual partners will shun then if they are HIV positive.
[34, 36, 61, 67, 69]
Testing as marital requirement.
In some churches, it is a requirement for Christians to test before marriage could be sanctioned by the church. Individuals also wait till it is time to get married before seeking HIV testing.
[31, 39, 40, 42, 46, 50, 58, 61]
Organisation/delivery of HIV services.
Opt-out HIV testing.
Routine offer of HIV testing to pregnant women & TB patients has shifted provider-service user power relationships in the testing process. Clients may fear being denied access to health care if they refused to test; sometimes women at antenatal care directed to bring their spouses for testing.
[29, 30, 35, 41, 53, 54, 57, 58],
Location of HIV testing facilities.
Isolated testing centers within health facilities creates a barrier as people fear being seen seeking HIV testing as this may imply being sexually activity and/or already being infected.
[34, 51, 52, 60, 61, 69]
Feminisation of health care settings.
Health care facilities, particularly antenatal clinics perceived by men as female domains, out of bounds for men.
[35, 52, 57, 67]
HIV testing as package of health care.
Providing HIV testing with non-HIV related interventions provides an incentive to test as this helps mask HIV testing as primary objective in settings characterized by stigma. Provision of material benefits (i.e. food aid) to those found HIV positive also encourage uptake of HIV testing.
Availability & efficacy of ART.
The availability of antiretroviral therapy & transformation of HIV into a manageable chronic condition has served as an incentive to test.
[30, 55, 59, 65, 66, 69]
| || |
However, the absence of/limited access to ART and the continued absence of a cure still inhibits uptake of testing.
[32, 40, 48, 54, 55, 65, 66, 68]
Burden of treatment for HIV-TB co-morbidity.
Patients with TB are subjected to (opt-out) HIV testing as part of care. However, dealing with the treatment burden of dual infections & double stigma forces them to deal with TB & HIV in succession rather than in concurrence, thus delaying uptake of testing.
[30, 45, 68]
Trust in the health system.
Quality of health care.
Perceived lack of confidentiality & privacy; perceived poor attitude of health staff affect health seeking behaviour. The use of non-familiar health personnel allays fears of breach of confidentiality, thus improving uptake of testing.
[28, 29, 33, 34, 40, 43, 46, 49],[52, 53, 55, 56, 60, 68]
Distrust of testing process & technology.
Perceived unreliability of test results, notions of testing instruments as sources of infection & association of drawing of blood with rituals inhibit uptake of HIV testing. Confidence in test technology, including encouraging clients read test results creates credibility of test results.
[33, 36, 42, 61]
HIV seen as a ‘plot’ by western countries to control/dominate SSA population & promote western interests.
Financial costs of HIV testing.
Indirect financial costs of HIV testing.
Long distance to testing sites & associated transport costs & travelling time discourage uptake of testing. Opportunity costs of travelling time, suspending livelihood activities & time of work inhibits HIV testing.
[33, 36, 42, 50, 52, 56, 57, 63],
Direct financial costs.
Convenience of testing i.e. home/workplace-based testing at attenuates associated costs and travel time. Where user charges are non-existent, this encourages testing; paying for services competes with other human needs.
[33–35, 39, 42, 47, 49, 50, 56, 57],