Factors influencing patients' interests in VCT
Many of our respondents (22) were not interested to attend VCT regardless of gender, age, education and marital status. Most patients (24) had no negative feeling towards the HIV test offer, though some (9) clearly felt offended:
Frankly, that time I was offended. From the beginning, it was already explained that HIV is transmitted by this and that, not all drug users get it, also not all 'others' [risk groups] get it. And then all the sudden they offered me HIV test? 23-year-old, male, university student, attended VCT
Knowledge of many respondents (11) on HIV was poor, ranging from those who had never heard of HIV to those who knew little. Patients with limited knowledge were less interested in VCT:
The problem is I don't even know what HF [HIV] is. Is it a new disease? I am just a lay person, so I don't know. It was my son who replied. [I told him] you should respond because you are the one who can answer. 52 year-old, male, employee, not interested in VCT
Well what can I say? That HIV is not scary. It's just another disease. It can be cured. 29-year-old, female, employee, not interested in VCT
Misconceptions regarding transmission of HIV/AIDS were common:
You can get infected through having a [sexual] relationship or through drugs or through smoking cigarettes, that's all I know. I heard it before from stories, you know, on TV. 26-year-old, male, unemployed, attended VCT
I would imagine, that people who get infected by HIV are those who keep changing partners. If one doesn't change partners and does not use illegal drugs, then probably [he/she] can't get infected. 45-year-old, male, construction worker, attended VCT
Table
2 summarizes the relations between main patients' perceptions and VCT interest. Many patients (16) did not report to perceive themselves at risk, or simply did not know enough to attribute risk (10):
Table 2
Patients' perceptions and interest for VCT
At risk of being infected | Yes | majority |
| No | minority |
VCT entails benefits | Yes | roughly half |
| No | small minority |
HIV patients are stigmatized | Yes | roughly half |
| No | minority |
Fear of knowing test result | Yes | small minority |
| No | vast majority |
Access to VCT is a burden | Yes | minority |
| No | vast minority |
It's just for a test. It's not because one gets TB that one will get HIV. I've never done anything [wrong]. So I don't mind and I am also looking for a new experience. I am confident that the result will be non-reactive. No worries whatsoever. I am sure, Insya Allah [God's willing], as the doctor already know, that I won't get it. I imagine if one gets it. Oh my God! 37-year-old, male, employee, attended VCT
I mean usually those who get HIV are those who like to go out at night, they like to...well, like commercial sex workers, they're like that, so they must get it. I never go out at night. I hardly leave my house. How can I get HIV? 29-year-old, female, employee, attended VCT
A few patients (7) accepted that they could be at risk and were interested in VCT:
I've never done anything wrong [risky], or had a [sexual] relationship with someone with HIV. I've never received blood transfusion, never. I don't believe I can get HIV but, there's a possibility I get it because of TB, they say that can make you get infected easily. 45-year-old, male, construction worker, attended VCT
No, I was already told [by the health worker] that from ...from the lungs it can lead to HIV. So I already knew beforehand. 24-year-old, female, self-employed, attended VCT
Nearly half of the patients (16) perceived a certain benefit of HIV testing, regardless of whether they reported to perceive themselves at risk or not. Many of these (9) expressed interest towards VCT:
Well, to be able to know [whether I get] AIDS or ...HIV. I was not surprised [to be offered HIV testing]. I wanted to be examined to see if I had other diseases. 26-year-old, male, unemployed, attended VCT
Some patients (10) perceived some stigmatization towards people living with HIV in the society. Others (8) did not perceive stigmatization, while the remaining participants (15) had no opinion. Most of those who perceived stigmatization (6) however were interested in VCT:
[They are] afraid to get infected, yes. Also afraid of ... what else...Well, it's a shameful and horrible disease. It's terrifying. So I would be afraid to be isolated, to be treated as someone infectious, as someone who has a pathetic disease. If I can, I will just avoid such disease. 29-year-old, female, attended VCT
Well, the problem is AIDS is... Well, it is a shameful disease. I don't know... The problem is most people who get AIDS are those who do wrong things. People where I live, if they know, they will avoid you immediately. 17-year-old, female, student, attended VCT
Some patients (5) feared knowing the HIV test result and were not interested in VCT, or initially expressed interest, but eventually changed their mind:
Why did it go that far? Saying HIV was like this and that. That made me scared. It's about psychology, I am sure I don't have HIV, but I am not mentally ready. It's enough that I got TB. If for instance I had to be tested for something like that [HIV], it could make things more complicated with so many problems...Oohhh! 23-year-old, male, student, not interested in VCT
If they take my blood again, then they will test it, then if it turns out that I have that disease, it's like being struck on the head, it's a mental burden. What I am afraid of is that there is no cure yet, you die because of HIV. So if there's no treatment you will just die. 23-year-old male, student, initially expressed interest, but did not attend VCT
A number of patients (8) also perceived burden for accessing and utilizing VCT. Most of these (6) were not interested in VCT.
The process would become too cumbersome. When I think about it, it will just make the process longer and complicated. My intention to seek treatment was just to get my coughs cured. 25-year-old, male, self-employed, not interested in VCT
Well, at that time I thought, if they can do it at that moment, I wouldn't mind. I thought it would take too much time. [I asked] how I would know the result. [They said] if I wanted to know I have to go there. How can I manage the time? 51-year-old, male, employee, not interested in VCT
Nurses' perceptions
Table
3 depicts the distribution of main issues perceived by nurses across different type of health facilities. Most nurses considered their knowledge of HIV-TB insufficient:
Table 3
Nurses' perceptions of barriers to introduce HIV testing among TB patients*
'Hard' patients | - | - | + | ++ |
Additional burden | +/- | +/- | ++ | ++ |
Patients offended | - | - | ++ | ++ |
Stigmatization | + | +/- | +++ | ++ |
Lack of facility | + | +++ | +/- | + |
Communication difficulty | +/- | +/- | ++ | +++ |
At the least, the lab technician, TB worker, nurse and doctor should know about the HIV issue comprehensively. Sometimes we go for training and bring home materials, but we don't really read them. There are patients who really need information on what is the relevance, goals. Yesterday there were two like that. At the end I had to read, I had to open the reference for them. The problem is we ourselves do not understand HIV comprehensively. Female, nurse, rural health centre
Nurses especially in the hospitals perceived that there are patients difficult to deal with, for instance skeptical highly educated patients. Nurses in hospitals also more frequently perceived offended patients as an issue:
Once we had a patient who was a high school teacher. We discussed how TB is the leading opportunistic infection for HIV. At the end it became confusing because the theory was not clear. At the end she refused. So how can we deal with patients who are highly educated? Female, nurse, rural health centre
Even though we have explained this and that...but in the end it doesn't seem to suffice. We really are not effective. Female, nurse, public hospital
The majority reacts negatively [to the offer]. Patients feel they have never done any wrongdoings. Patients feel they could not get it. Especially the VIPs [Very Important Person – Patients in first class wards]. All the VIPs refused. Female, nurse, private hospital
Lack of facilities was an issue perceived by nurses of all types of structures:
The room is still mixed [with other patients]. So, if possible, a separate room, which would be better to give patient education. It's inconvenient for us to do it when there are other patients around. Male, nurse, public hospital
We don't have a special room. Our place until now is semi-permanent, so mixed Maybe it wasn't convenient to offer the test to the patients under such condition. Female, nurse, rural health centre
Nurses at all facilities perceived some burden due to having to offer an HIV test, particularly with limited time available:
We don't have enough staff, for our lung clinic. It's just me and one assistant. If there are many patients we really don't have time, really too overwhelmed to offer [HIV testing]. We have more time in the morning. Those patients who accepted the offer are usually those who come in the morning. Female, nurse, private hospital
Nurses in hospitals particularly perceived difficulties in communication, mainly when it comes to patients who are 'hard' to deal with:
If they have detailed questions we have difficulty in explaining in details. We can handle general questions, but university students ask a lot of questions which are beyond our knowledge. Female, nurse, private hospital
Stigmatization of people living with HIV/AIDS within the community was perceived to be a barrier, particularly in hospitals:
They had fear, what if they turn out to be [HIV] positive? What would happen when they have to face the community. Some of them are community leaders. Female, nurse, private hospital
Strikingly, a few nurses' comments suggested that some nurses stigmatize people living with HIV:
We're also worried, what if nurses get it too? It will [then] become very risky for [HIV-negative] patients. We need to isolate them if we can identify them, but until now we don't know who is positive and who is not. Even if it's [just] gonorrhoea and somebody [staff] knows, everyone [staffs' behaviour] becomes different. Female, nurse, public hospital
Perceptions of decision makers: specialists and disease control managers
Both specialists and disease control managers perceived patient-provider communication and stigmatization as important barriers to VCT uptake:
Yes, I've observed that some health workers really can't talk, they can't communicate. Really, it's not that they don't want to do it, but they simply don't have the capacity to do it. So we can't do anything, because they are all we got. Female, disease control manager, urban district
What I liked about the programme [introducing HIV testing among TB patients] was that the TB patients got more attention. There was a demand to the health worker to be able to communicate better. We basically have nurses and doctors who can communicate well, but the majority have limited communication skills and it's not just a matter of education, it's also about personality. Male, disease control manager, rural district
Specialists seemed to be more optimistic, giving more emphasis on the managerial challenges than on the operational:
The most important thing is that this is integrated at the top level. If this is still under two different national programmes then it will be difficult for policy making. If it's integrated at the top level, [we] at the frontline just have to implement. But if at the top there are still two heads, what can we do? It's a sensitive issue, but that's the reality. Male, senior lung specialist, public chest clinic and private hospital
The management system needs to be repaired. If we're integrating TB and HIV, the management becomes more [crucial]. Especially that we're involving two different national programmes together. The financing, the organization... Male, junior lung specialist, teaching hospital and private hospital
They also perceived much less additional burden:
I don't feel any [significant] additional burden. As far as I've observed, care delivery was not disrupted. Of course there were some additional things [tasks], but not so much. Male, senior lung specialist, public chest clinic and private hospital
However, specialists strongly perceived lack of knowledge on HIV to be a major hindrance to introduce testing, including among colleagues:
Even in this hospital, other specialists don't really know [about HIV]. Internal medicine and dermatovenereology [specialists] know quite a bit, but others still ask a lot of questions. They only know it superficially. Male, internist, private and teaching hospital
But both district control managers and specialists were not concerned with potential harms to the TB control programme's performance:
"No, I am not worried, the patients were not obliged to be tested ... and I've observed no reduction of case reporting so far. Our patients were not running away". Female, disease control manager, urban district