Concerns about covert HIV testing are associated with delayed presentation in Ethiopian adults with suspected malaria: a cross-sectional study

Malaria is an important treatable cause of morbidity and mortality, with 3.4 billion people globally estimated to be at risk of infection in 2012, resulting in approximately 200 million cases of malarial infection and 600,000 deaths annually [1]. In Ethiopia, malaria is one of the most important public health problems, representing the commonest communicable disease [2] and imposing a high economic cost on the country [3]. As malaria is treatable with prompt medical care [4], the national malaria programme stresses the importance of early treatment-seeking behaviour for suspected infection [2].

Ethiopia is one of the countries in the sub-Saharan Africa that have a generalized human immunodeficiency virus (HIV) epidemic with about 750,000 people living with HIV/AIDS [5]. The prevalence of HIV infection among adults aged 15–49 years old in 2011 was estimated to be 4.2 % in urban areas and 0.6 % in rural areas [6]. Despite the availability of anti-retroviral treatment, individuals may be reluctant to undergo testing of their HIV status, as they do not wish to be exposed to the knowledge and social consequences of a potential positive diagnosis.

We recently reported data demonstrating that presentation of children with suspected malaria was delayed if their guardian were concerned that blood samples collected for malaria diagnosis were being covertly tested for HIV status without consent [7]. A similar hypothesis was tested in adults, speculating that concerns about covert HIV testing were common and resulted in delay in the presentation of symptomatic patients for investigation of malaria. This hypothesis was tested using a cross-sectional observational study design in Ethiopia in adults with suspected malaria visiting health centres.

This is the first quantitative study to specifically assess the prevalence of concerns about HIV testing and associations with the time to presentation at health centres of adults with suspected malaria living in Ethiopia. Our analysis shows that half of the individuals with suspected malaria were concerned that HIV testing was implemented on all blood sampled for the diagnosis of malaria, and that 40 % of our respondents considered that these beliefs will result in relatively later presentation at medical facilities for symptomatic patients. Collectively, these concerns about covert HIV testing were associated with delayed presentation for management of suspected malaria, with these associations a consequence of data from Meki health centre in particular.

The study has a number of strengths including the prospective assessment of a priori hypothesis from a population of adults with suspected malaria, who were unaware of the hypothesis being tested, with a very high response rate (minimising bias). The main limitation of these data is the issue of generalisabilty to other cultural settings. Although these observations are valid within the communities in Central Ethiopia that we studied, it is impossible to assume that these concerns regarding HIV testing and delayed access to health care in general are applicable elsewhere. In addition, our study population could be biased by severity of disease, so that those with more advanced disease are unable to attend the health centres, and hence our observations are pertinent only to those who attend health centres with symptoms of malaria, although this is unlikely to account for the association between delayed presentation and concerns about HIV testing. Our data should thus be considered to be hypothesis generating, and further regional studies are required in a number of different settings to determine how prevalent the beliefs are that covert HIV testing accompanies malaria blood testing in high HIV prevalence countries.

A delay of over two days before obtaining medical assessment after the initiation of symptoms of suspected malaria occurred in 56 % of our study population, and similar delays have been observed in Nigeria [8], Senegal [9], Ethiopia [10, 11] and India [12, 13]. However, our data were cross-sectional and demonstrating causality is not possible using this study design. Future studies should consider using representative prospective study designs to study local differences in baseline attitudes to HIV testing, and in particular their possible association with late presentation of patients with malarial symptoms, adjusting for potential confounding factors such as access to health facilities.

The current study was performed at the same time as a second study that tested a related hypothesis in children presenting with suspected malaria [7]. These data demonstrated that 51 % of guardians of these children perceived that HIV testing was done on blood donated for malaria diagnosis, which is similar to the 50 % reported in the current data. Children whose guardians were concerned about covert HIV testing in cases of suspected malaria presented later with a median delay of three days compared to those children whose guardians were not concerned about covert HIV testing who had a median value of two days. While antiretroviral testing and therapy is available in Ethiopia, the disease remains a public health concern with stigma of having HIV infection being a particular problem despite the regular promotion of health awareness campaigns to educate the local population. The analysis stratified by health centre demonstrated that the prevalence of concern about HIV testing was common across all the regions studied, with values ranging from 45 to 54 % of the populations studied, suggesting that this was not localised to just one area. However, only in one health centre (Meki) did this translate into a delay in presentation, and further investigation is required to account for this. The fact that level of education attained does not modify the concerns about covert HIV testing is an important negative finding, that should inform future investigations in this area, as these concerns are shared across all educational groups.

Our data can be compared with those from Gambella Region of Ethiopia in 2008, where the prevalence of refusal for HIV testing among women attending for antenatal care was 25 % [14], suggesting that there may be a substantial minority of individuals in Ethiopia who do not want to take advantage of HIV testing to know their serological status. To date, sparse data exist on how attitudes to HIV impact on presentation with symptoms of malaria. Individuals living in rural Cote d’Ivoire who were offered a rapid diagnostic testing assay for malaria reported that 67 % had concerns that the blood would be used for HIV testing [15]. In Uganda, two separate qualitative studies explored the feasibility of introducing rapid diagnostic malaria assays. In the first qualitative study, the local population again expressed concern that blood samples collected for malaria could be used for HIV testing rather than malaria [16]. In the second qualitative study, again individuals were worried that ‘in most communities people think that taking of blood means testing for HIV and some do not want their HIV status disclosed’ [17].

These data suggest that concerns about covert HIV testing without informed consent are common in central Ethiopia, and that these may result in delayed presentation by adults with suspected malaria for medical treatment. This provides a relatively novel risk factor that inhibits prompt treatment of patients with malarial symptoms that is potentially reversible, and provides the option of testing non-medical interventions to improve earlier presentation and hence treatment for this common infection.